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AND   SURGEONS 


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SURGERY 


ITS  PRINCIPLES  ANT)  l^RACTTCE 


FOR  ST[TDENTS  AND  PRACTITIONERS 


BY 

ASTLEY  PASTON  CoOPER  ASHHUIIST.  A.B.,  M.D.,  F.A.CS 

INSTRUCTOR    IN    SURGERY   IN   THE   UNIVERSITY    OF    PENNSYLVANIA,    ASSOCIATE   SURGEON    TO    THE 

EPISCOPAL   HOSPITAL   AND    ASSISTANT    SURGEON   TO   THE    PHILADELPHIA    ORTHOP-EDIC 

HOSPITAL    AND    INFIRMARY    FOR     NERVOUS    DISEASES 


WITH   7  COLORED  PLATES  AND  1032    ILLUSTRATIONS  IN  THE  TEXT 
MOSTLY  ORIGINAL 


LEA  &   FEBIGER 

PHILADELPHIA   AND    X  E  \V   YORK 


Entered  according  to  the  Act  of  Congress,  in  the  N-ear  1914,  bj^ 

LEA   &   FEBIGER, 
in  the  Office  of  the  Librarian  of  Congress.     All  rights  reserved. 


TO 

RICHARD  H.  HARTE 

A     SIRGEOX     OF     WIDE     CLINICAL     EXPERIENCE 

AX    ABLE    TEACHER 

A    WISE    CONSULTANT 

A    SAFE    AND    SKILFUL    OPERATOR 

THIS    VOLUME 

IS    GRATEFULLY    DEDICATED 
BY    HIS    PUPIL,    ASSISTANT    AND    FRIEND 

THE   AUTHOR 


I'liKKACK. 


I'j"  is  the  function  of  a  work  such  as  this  to  furnish  the  foundation 
on  which  a  knowledjje  of  Surgery  is  to  be  built.  Didactic  and  chnical 
lectures,  i)apers  in  current  journals,  classical  monographs,  and  par- 
ticularly the  student's  clinical  work  and  the  surgeon's  daily  practice 
are  valuable  adjuncts,  but  unless  the  foundations  have  been  laid 
broad  and  deep,  no  useful  superstructure  can  be  erected. 

A  text-book  shoukl  afford  a  true  perspective,  placing  the  various 
branches  of  study  in  their  proper  relative  position,  maintaining  their 
just  proportions,  and  providing  a  source  of  information  which  shall 
indicate  where  further  knowledge  is  to  be  gained.  A  student  seeks 
clear  and  accurate  statements,  and  desires  to  have  facts  set  definitely 
before  him.  If  the  present  volume  supplies  these  wants,  if  it  helps 
the  student  to  learn  surgery  and  proves  a  useful  reference  work  for 
the  practitioner,  it  will  have  fulfilled  its  purpose. 

Every  text-book,  however,  has  its  limitations.  At  best  it  can  but 
teach  the  student  to  know;  it  cannot  teach  him  to  do.  And  though 
knowledge  is  power,  much  practical  experience  in  laboratory,  dis- 
pensary and  hospital  wards  must  supplement  didactic  instruction. 
In  the  present  work  emphasis  is  placed  on  the  underlying  principles, 
and  pathogenesis,  diagnosis^  and  indications  for  treatment  have 
received  particular  attention.  Descriptions  of  operations,  however, 
have  not  been  slighted.  The  more  important  operations  have  been 
described  in  detail,  and  in  every  case  an  attempt  has  been  made  to 
present  clearly,  if  briefly,  at  least  one  method  of  operative  procedure. 
The  specialties  of  the  Eye,  the  Ear,  the  Nose,  and  the  Throat  naturally 
are  not  included;  and  Genito-urinary  Surgery,  Gynecology,  and 
Orthopedics  have  been  discussed  only  so  far  as  they  come  within 
the  province  of  the  general  surgeon. 

Neither  publishers  nor  author  have  spared  any  pains  in  the  endeavor 
to  furnish  a  text-book  on  Surgery  w^hich  shall  be  acceptable  to  the 
profession.  The  illustrations,  with  very  few  exceptions,  are  entirely 
original,  and  are  reproductions  of  photographs  or  sketches  made  by 
the  writer  in  his  various  services,  especially  at  the  Episcopal  Hospital 
of  Philadelphia.  To  his  long  association  with  this  Hospital  he  owes 
unsurpassed  opportunities  for  clinical  work;  as  well  as  to  his  associa- 
tion with  the  Orthopaedic  Hospital,  and  to  his  former  services  at  the 
Pennsylvania,  the  Children's,  and  the  German  Hospitals.  Most  of 
the  skiagraphs  are  derived  from  the  Episcopal  Hospital,  and  were 
made  by  Dr.  Thomas  S.  Stew^art  or  his  Assistant,  Dr.  A.  U.  Wilkinson. 


vi  PREFACE 

Those  from  the  Orthopiedic  Hospital  were  made  by  Dr.  Wm.  \nn 
Korb.  The  ilhistrations  of  operative  technique  are  based  largely  on 
work  done  in  the  writer's  Laboratory  of  Operative  Surgery  in  the 
I'niversity  of  Pennsyhaiiia.  The  credit  for  converting  the  author's 
diagrams  and  photographs  into  admirable  illustrations  is  due  to 
Mr.  Charles  F.  Bauer. 

Much  help  has  been  derived  from  other  text-l)ooks  and  systems  of 
surgery.  First  and  foremost  among  these  must  be  mentioned  the 
Principles  and  Practice  of  Surgery  of  John  Ashhurst,  Jr.  The  indebted- 
ness of  the  writer  of  the  present  work  to  that  \olume  can  be  appre- 
ciated best  by  those  who,  like  himself,  acquired  the  basis  of  their 
surgical  education  from  its  pages.  Every  other  source  of  inff)rmation 
has  been  studiously  sought;  and,  thanks  to  the  facilities  afforded  by 
the  Library  of  the  College  of  Physicians  of  Philadelphia,  this  laborious 
task  has  been  rendered  comparatively  easy.  It  was  thought  inadvis- 
able to  cumber  the  text  with  bibliographical  references,  but  the  dates 
of  publication  of  authoritative  contributions,  whether  recent  or  of 
historical  interest,  have  been  indicated,  and  it  is  believed  that  by  this 
means  the  original  references  may  be  more  easily  found  in  the  Index 
Medicus  or  in  the  I^idex  Catalogue  of  the  Surgeon- GeneraVs  Library, 
U.  S.  Army.  The  author  is  particularly  indebted  to  the  Avritings 
of  Deaver  on  abdominal  and  prostatic  surgery;  and  free  citations 
have  been  made  from  the  \olumes  pu])lishcd  In-  this  brilliant  surgeon 
in  collaboration  with  the  writer. 

The  text  of  the  present  volume  has  receixcd  the  criticisms  of  several 
of  the  author's  friends.  Dr.  Henry  Winsor  and  Dr.  Penn-Gaskell 
Skillern,  Jr.,  have  devoted  themselves  to  this  work  most  unselfishly, 
and  have  offered  many  valuable  corrections  and  suggestions.  Dr. 
G.  G.  Davis  and  Dr.  Frank  D.  Dickson  have  kindly  reviewed  the 
chapters  on  Orthopedic  Surgery  and  on  Diseases  of  the  Joints.  Dr. 
A.  D.  Whiting  has  assisted  in  reading  the  proof-sheets,  and  has  made 
the  index. 

A.  P.  C.  A. 

811  Spruce  Street,  Philadelphia,  1914. 


(  onti:nts. 


GENERAL  SURGERY. 

("HAPTKR    I. 
Inflammation' 17 

CHAPTER    II. 
Diseases  Resulting  from  Inflammation 47 

CHAPTER    111. 
MoDiFiKU  Forms  of  Inflammation  (^8urc;ical  Infections)      ....         7t) 

CHAPTER    IV. 

Tl-MOHS 101 

CHAPTER    V. 
SuROK.'AL  Techniqie 133 

CHAPTER    VI.                                       ' 
I.nmuries  and  their  Effects 159 

CHAPTER    VII. 
Gunshot  Wounds 180 

CHAPTER    VIII. 
Amp[t.\tions 192 

CH.M'TER    IX. 

Effects  of  Heat  and  Cold;  Injuries  by  Electric  Currents,  Lightning 

AND  the  Rontgex  Rays;  Skin-grafting  and  Plastic  Surgery    .      .       217 


viii  CONTENTS 

SYSTEMIC  SURGERY. 

CHAPTER    X. 
.Surgery  of  the  BLOOD-VASfULAU  System 227 

CHAPTER   XI. 

Surgery  of  the  Skin,  Bur.s.-e,  Lymphatics,  Muscles,  Tendons,  and 

Nerves 259 

CHAPTER   XII. 
Fractures 294 

CHAPTER  XHI. 
Injuries  of  Joints .       385 

CHAPTER  XIV. 

Diseases  of  Bone 416 

CHAPTER   XV. 

Diseases  of  Joints 451 

CHAPTER    XVI. 
Orthopedic  SuRCiERY ^^4 

REGIONAL  SURGERY. 

CHAPTER    XVII. 

SUR(iKHY   OF  THE    HeAD ^^1 

CHAPTER   XVII I. 
Surgery  of  the  Spine ^^^ 

CHAPTER   XIX. 

Surgery  of  the  Face,  Mouth,  and  Neck •>19 

CHAPTER   XX. 


Surgery  of  the  Breast,  Chest  Wall,  Lungs,  and  Diaphragm 


699 


CONTENTS  IX 

ClIAFTKll   XXI. 
Hkrnia 753 

C'lIAPTKK    XXII. 

AuDOMINALSuKCIKKY  in  GeNEHAL,  and  LnJUKIES  OI' the  AI3U0.M1NAI>  VlSCEHA  802 

CHAPTER   XXIII. 
Surgery  of  the  Ga.stro-inte.stinal  Tract 848 

CHAPTER   XXIV. 

Surgery  of  the  Call-uladder,  Liver,  Pancre.\s,  and  Spleen  919 

CHAPTER   XXV. 

Surgery  of  the  Bladder  and  Kidneys 958 

CHAPTER   XXVI. 
Venereal  Diseases '   .      .      .       989 

CHAPTER  XXVII. 

Surgery'  of  the  Urethra  and  Prostate 1015 

CHAPTER   XXVIII. 
Surgery' of  the  Male  Genital  Org.\ns 1043 

CHAPTER   XXIX. 

Surgery  of  the  Female  Genitals 1064 


SLIllGERV;  ITS  I'liLNCIPI.ES  A.XJ)  I'llACTICE. 


The  word  Surj^ery  (old  English  Chirurgery)  is  derived  from  two 
Greek  words,  yt'-i'  and  ^l')'"'",  signifying  respectively  hand  and  work; 
as  distingnished  from  the  work  of  the  physician,  surgery  was  there- 
fore formerly  confined  to  such  mechanical  procedures  as  were  carried 
out  by  the  surgeon  under  the  direction  of  the  physician.  Such  was 
the  position  of  the  surgeon  in  the  middle  ages;  but,  since  the  time  of 
Ambroise  Pare  (1509-1.190),  who  is  thus  justly  styled  the  Father  of 
Modern  Surgery,  the  Science  and  Art  of  Surgery  have  advanced  step 
by  step  toward  such  a  point  of  perfection  as  long  since  to  have  entitled 
them  to  equal  rank  with  ^Medicine.  And  though  the  highest  func- 
tions of  surgery  still  remain  mechanical  in  nature,  it  is  no  longer  the 
physician  who  plans  and  directs  the  mechanical  treatment,  but  the 
surgeon  himself  who  selects  the  patient,  devises  the  operation,  and 
determines  at  what  stage  of  the  malady  surgical  measures  shall  be 
employed. 

Underlying  all  disease,  and  therefore  necessary  to  an  understand- 
ing of  disease  processes,  surgeons  encounter  a  pathological  state 
which  constitutes  the  process  by  which  the  bodily  tissues  react  to 
injury.  If  the  injury  be  very  severe,  immediate  death  of  the  part 
may  ensue;  and  there  will  then  be,  in  that  part,  no  reaction  to  the 
injury.  At  the  \ev\  outset  of  the  study  of  surgery,  it  is  proper  to 
discuss  at  some  length  the  reaction  which  takes  place  when  the  tissues 
are  injured,  because  only  when  the  underlying  principles  of  disease 
and  injury  ha\'e  been  thoroughly  mastered,  can  it  be  hoped  to  study 
with  profit  the  special  affections  which  subsequently  will  be  discussed. 


chapter  i. 
l\fla:\imation. 

The  process  by  which  the  tissues  react  to  an  irritant  is  known  as 
Inflammation.  The  student  must  therefore  learn  what  are  the  usual 
irritants  which  produce  these  changes;  he  must  study  the  changes 
themselves,  and  their  results;  he  must  familiarize  himself  with  the 
subjective  and  objective  symptoms  due  to  these  tissue  changes;  and 
he  must  finally  learn  how  to  relieve  the  patient  of  his  suft'ering.    It 


1 8  IX  FLA  MM  A  TION 

therefore  becomes  necessary  to  discuss  the  causes,  the  pathology,  the 
symptoms,  and  the  treatment  of  inflammation. 

Causes. — The  predisposing  causes  of  inflammation  are  those  which 
render  the  patient  especially  liable  to  the  action  of  irritants,  which 
are  the  exciting  causes.  Any  constitutional  state,  therefore,  which 
lowers  the  resistance  to  disease  or  injury  will  act  as  a  predisposing 
cause.  Age,  especially  the  extremes  of  life,  influences  the  develop- 
ment of  inflammation  in  this  way.  Occupation  and  habits  also  have 
an  undoubted  influence,  by  undermining  or  by  strengthening  the  con- 
stitution. Past  or  present  diseases  may  very  seriously  modify  the 
patient's  resistance  to  the  exciting  causes  of  inflammation. 

In  general  it  may  be  admitted  that  the  exciting  or  determining 
causes  of  inflammation  are  either  mechanical  or  chemical,  using  these 
terms  in  their  broadest  sense,  and  including  in  the  latter  all  causes 
(thermal,  electrical,  radio-active,  infective)  which  are  not  distinctly 
mechanical  in  their  action.  But  while  it  is  expedient  to  acknowl- 
edge that  the  process  of  repair  which  occurs  after  such  mechanical 
injuries  as  contusions,  fractures,  aseptic  wounds,  and  the  like  is  in 
very  fact  an  inflammatory  process,  it  is  nevertheless  proper  to  recog- 
nize the  fact  that  the  vast  majority  of  inflammatory  affections  are 
directly  due  to  chemical  irritants  produced  in  the  tissues  by  micro- 
organisms, especially  bacteria.  Indeed,  it  is  seldom  susceptible  of 
satisfactory  proof  that  bacteria  are  entirely  absent  in  the  class  of 
injuries  first  mentioned;  for  it  is  probable  that  all  patients,  and  even 
persons  in  good  health  (Adami),  have  somewhere  in  their  system 
certain  bacteria  which,  being  carried  by  the  blood  or  lymph  currents, 
eventually  will  reach  the  region  of  damaged  tissue,  and  will  there  be 
enabled  to  prosecute  their  nefarious  work  to  better  advantage  than 
where  there  exists  no  locus  minoris  resistentioe . 

Foreign  bodies  were  cited  formerly  as  examples  of  purely  mechani- 
cal causes  of  inflammation;  but  unless  it  can  be  proved  that  the 
foreign  body  is  aseptic,  and  that  the  part  of  the  body  where  it  lodges 
(eye,  skin)  is  also  free  from  bacteria,  it  is  proper  to  assume  even  in 
such  cases  that  the  resulting  inflammatory  reaction,  if  noticeable, 
is  due  as  much  to  bacteria  as  to  the  presence  of  a  foreign  body. 
Indeed,  we  know  that  many  sterile  foreign  bodies  (ligatures,  sutures) 
constantly  remain  in  the  tissues  after  aseptic  operations,  and  are 
productive  of  no  manifest  inflammatory  reaction.  Likewise  calculi, 
formed  in  the  internal  organs,  if  sterile  themselves,  may  be  productive 
of  only  trivial  discomfort  until  bacterial  infection  occurs  in  their 
containing  viscus. 

The  bacteria  which  surgeons  most  frequently  encounter  as  causes 
of  inflammation  are  the  Micrococcus  pyogenes  (Staphylococcus); 
Streptococcus  pyogenes;  Bacillus  coli  commimis;  Gonococcus; 
Bacillus  pyocyaneus;  Pneumococcus;  Bacillus  typhosus;  Bacillus 
tuberculosis;  Bacillus  tetani;  Bacillus  mallei;  Bacillus  anthracis; 
Bacillus  oedematis  maligni;  Bacillus  aerogenes  capsulatus,  etc. 
These  microorganisms  are    known    as  Pathogenic   Bacteria,  because 


PArilOLOGY  19 

they  are  thcnisolves  the  causes  of  (Hsease;  tliey  take  up  their  abode 
and  thri\e  in  li\iug  tissues,  which  tliey  use  as  pahuhun.  Tliey  are 
to  be  distinguished  from  Saprophytic  Bacteria,  which  exist  only  in 
dead  tissues;  these  can  be  rep;arded  as  causes  of  disease  only  in  a  more 
or  less  indirect  maimer,  because  it  is  necessary  that  other  agents, 
chiefly  the  patliogenic  bacteria,  shall  have  previously  brought  about 
the  death  of  the  tissues. 

In  addition  to  bacteria,  certain  other  forms  of  microorganismal 
life  must  be  recognized  as  occasional  causes  of  the  inflammatory 
process  in  man.  Among  these  are  certain  animal  parasites,  certain 
Yeasts,  or  Blastomycetes,  and  certain  ^loulds,  or  IIyi)homycctes. 
Among  the  more  important  of  the  latter  may  be  mentioned  Oidium 
Albicans,  which  causes  Thrush;  the  various  forms  of  fungi,  which  cause 
the  skin  lesions  of  favus,  tinea,  etc.;  and  the  Ray  Fungus,  which 
causes  Actinomycosis. 

The  chemical  substances  produced  by  pathogenic  bacteria,  as  a 
result  of  their  action  upon  the  tissues,  are  described  by  the  general 
name  toxiris  (Roux  and  Yersin,  1888);  endo-toxins  are  those  substances 
formed  in  the  bodies  of  dead  or  dying  bacteria.  Both  toxins  and 
endo-toxins  act  as  chemical  irritants,  and  it  is  these  products  of 
bacteria,  and  not  the  bacteria  themselves,  w^hich  are  regarded  as 
causes  of  inflammation.  The  products  of  pathogenic  bacteria  are 
albnniinoid  in  nature;  those  elaborated  by  saprophytic  bacteria  are 
alkaloidal,  and  go  by  the  general  name  ptomains.  The  action  of  thermal, 
electrical,  and  radio-active  agents  as  causes  of  inflammation  will  be 
discussed  under  separate  sections  in  other  portions  of  this  volume. 

Pathology. — The  pathology  of  the  inflammatory  process  is  the  same 
in  kind,  though  varying  somewhat  in  its  characteristics,  according 
to  the  irritant  cause,  and  to  the  particular  tissue  aflfected.  Certain 
bacteria  produce  a  reaction  so  peculiarly  characteristic  that  surgeons 
have  dignified  the  resulting  processes  by  erecting  them  into  diseases 
to  which  special  names  are  applied.  Such  are  Tuberculosis,  Syphilis, 
Anthrax,  Glanders,  and  other  affections  which  are  grouped  together 
as  the  Infectious  Granulomas.  These  diseases  therefore  are  described 
in  a  separate  chapter  (Chapter  III);  in  the  present  chapter  will  be 
described  only  those  changes  which  are  usually  understood  when  the 
term  inflammation  is  used.  Even  among  the  })acteria  which  cause 
the  changes  universally  recognized  as  inflammation,  the  form  of 
reaction  varies  considerably,  so  that  it  is  sometimes  possible  to  assert 
without  microscopical  or  bacteriological  examination  that  the  inflam- 
mation is  due  to  one  variety  of  bacteria,  not  to  another.  It  is  also 
sometimes  possible  for  the  experienced  observer  to  assert  that  the 
same  variety  of  microorganism  is  the  cause  of  quite  divergent  types 
of  inflammation  in  different  organs  or  tissues  of  the  body. 

If  one  were  to  watch  under  the  microscope  the  changes  which  occur 
in  a  part  on  which  an  irritant  is  acting,  he  would  obtain  a  very  accurate 
idea  of  the  process  of  inflammation.  This  may  be  done  in  the  patho- 
logical laboratory;  but  great  experience  is  required  properly  to  inter- 


20 


/.VF/..LV.V.4  770.V 


pret  what  is  seen;  and  for  practical  purposes  it  is  better  to  study,  at 
leisure,  a  series  of  illustrations  of  an  inflamed  area,  made  at  various 
stages  of  the  process. 

Studyintr  first  the  vascular  tiss-ues,  it  is  noted  that  the  capillaries 
dilate,  those  which  before  were  too  small  to  allow  the  entrance  of  the 
cellular  elements  of  the  blood  now  increase  in  diameter,  and  it  is  even 
possible  that  new  vascular  channels  may  be  formed.  More  blood 
comes  to  the  part,  more  blood  passes  through  it,  and  more  blood 
leaves  it,  than  in  the  normal  state.  This  change  is  spoken  of  as  active 
hyperemia  {determination,  fluxion  of  blood j,  to  distinguish  it  from 
passive  hyperemia  or  congestion;  in  this  latter  state,  although  there  is 
more  blood  actually  in  the  part  than  in  the  normal  state,  yet  the  blood 


^■%f/^^'"^'  M:^ 


Fig.  1. — Subcutaneous  tissue  some  distance  above  dead  part  in  a  case  of  spreading 
gangrene.  Note  stasi-'i,  margination,  and  inigration.  Three  veins  packed  with  leuko- 
cytes (I),  which  are  escaping  freely.  Around  the  arterj-  (below)  there  are  none.  Out- 
side the  vessels  many  larger  cells  are  seen.      X  200.     (Green.) 


is  more  or  less  stagnated  in  the  part,  and  does  not  leave  it.  owing  to 
venous  obstruction,  which  is  the  prime  cause  of  the  congestion.  In 
inflammation,  although  no  cause  of  venous  obstruction  exists,  the 
active  hyperemia  above  described  soon  undergoes  a  change,  so  that 
the  picture  more  nearly  resembles  that  seen  in  congestion.  The 
blood  moves  more  slowly  through  the  vessels,  the  blood  cells,  espe- 
cially the  leukocytes,  tend  to  cling  to  the  vessel  walls  (margination), 
and  eventually  some  of  the  leukocytes  escape  through  spaces  between 
the  endothelial  cells  lining  the  capillaries  by  a  process  known  as  migra- 
tion (.1.  F.  Cohnheim.  ISfi?).  In  some  cases  of  severe  inflammation 
the  erythrocytes  may  be  forced  out  of  the  vessels  as  well  ((liapefh'sis). 
In  the  case  of  the  leukocytes,  however,  the  process  is  active  (migration), 
and  is  not  a  mere  matter  of  filtration  by  the  vis  a  tergo.    According 


p.\Tiioj/)(;y  21 

to  recent  observations  it  seems  prohiihle  that  the  en  throcytes  escape 
from  the  vesssels  in  tlie  wake  of  the  knikocytes,  heiiifj:;  sncked  out  by 
the  currents  i)ro(hice<l  in  the  bhiod-phisma  by  the  migration  of  the 
wliite  bh)o(l  cells.  In  the  process  of  migration  of  the  Icnkocytes, 
first  a  portion  of  the  cytoplasm,  projected  as  a  pseudojjod,  emerges 
through  the  vascular  wall;  then  more  of  the  cell  body  follows;  and 
finally  the  portion  still  remaining  within  the  bloodvessel  flows  out  into 
that  portion  which  has  already  migrated.  It  has  been  noted  by  Coun- 
cilman that  the  portion  of  the  cell  to  migrate  first  always  contains 
the  nucleus;  and  it  has  been  suggested  by  Adami  and  others  that 
there  exists  some  relationship  between  "the  labile,  broken-up  char- 
acter" of  the  nucleus  of  i)()lymorphonuclear  leukocytes  (perhai)s 
karyokinetic  figures)  and  their  function  of  migration  through  the 
vessel  walls. 

It  is  further  evident  that  some  of  the  plasma  of  the  blood  has 
escaped  from  the  vascular  channels  and  is  infiltrating  the  perivas- 
cular connecti\e  tissue;  for  the  connective  tissue  cells  may  be  seen 
to  swell  up  and  become  engorged  with  foreign  fluid.  This  fluid  exudate, 
however,  is  not  unaltered  blood-plasma;  it  contains  a  higher  per- 
centage of  proteids,  and  its  specific  gravity  is  higher;  it  also  coagu- 
lates more  quickly.  Moreover,  as  will  be  pointed  out  presently,  it 
is  extremely  rich  in  bactericidal  and  antitoxic  substances.  The 
increase  of  serum  in  an  inflamed  part  is  frequently  very  apparent 
macroscopically  when  incisions  are  made  to  relieve  tension,  especially 
in  the  loose  subcutaneous  tissues;  and  when  inflammation  occurs  on 
free  surfaces,  as  the  peritoneum  or  the  mucous  membranes,  or  just 
beneath  the  cuticle,  as  in  blisters,  the  outpouring  of  this  fluid  exudate 
is  very  evident.  Its  quantity  and  quality  are  also  influenced  by  the 
variety  of  bacteria  present. 

Looking  a  little  later  at  the  inflamed  area,  the  first  thing  to  be  noted 
is  that  there  has  accumulated  in  the  perivascular  tissues  an  immense 
aggregation  of  small  round  cells.  These  cells  accumulate  in  response 
to  an  influence  of  chemical  nature  exerted  upon  them  by  the  bacteria 
or  other  irritant;  this  influence  is  known  as  chemotactic  action 
(Pfeffer,  1888^,  and  because  the  cells  are  drawn  toward  the  acting 
body,  we  speak  of  it  as  positive  chemotaxis,  in  contradistinction  to 
negative  chemotaxis,  which  term  is  used  to  describe  the  repelling 
action  of  certain  cells  or  microorganisms.  It  is  now  regarded  as 
certain  that  the  endothelial  cells  lining  the  bloodvessel  walls  take  an 
active  part  in  the  production  of  this  round-cell  infiltration,  under 
the  influence  of  the  positive  chemotactic  action  of  the  irritant.  These 
endothelial  cells  may  be  seen  to  swell  up  and  bulge  into  the  lumen  of 
the  vessels.  In  this  manner  they  seem  to  become  possessed  of  agglu- 
tinative characteristics,  which  aid  in  slowing  the  blood  stream  and 
in  producing  the  margination  of  the  leukocytes  already  described. 
It  is  not  impossible  that,  by  their  change  of  form,  these  endothelial 

1  According  to  the  late  Prof.  Ashhurst,  the  germ  of  the  idea  of  chemotaxis  is 
to  be  found  in  the  writings  of  Haller. 


22  INFLAMMATION 

cells  may  render  the  vessel  walls  more  readily  permeable  to  the 
leukocytes. 

The  origin  of  this  vast  aggregation  of  round  cells  next  engages 
our  attention.  By  reference  to  our  previous  study  of  the  changes 
in  the  vascular  tissues,  it  is  quite  evident  that  large  numbers  of  the 
round  cells  found  in  the  inflamed  tissues  have  been  derived  from  the 
leukocytes  of  the  blood  by  migration.  But  even  in  tissues  without 
bloodvessels,  such  as  the  cornea,  a  similar  aggregation  of  cells  occurs 
in  inflammation;  so  that  it  is  manifest  that  much  of  the  round-cell 
infiltration  is  derived  from  other  sources  than  the  bloodvessels. 
These  other  sources  are  the  lymph  cells,  which  exist  in  the  perivas- 
cular tissues  within  the  lymph  spaces  and  lymph  capillaries;  and  the 
fixed  connective  tissue  cells,  which  as  the  result  of  a  retrograde 
metamorphosis  come  again  to  resemble  the  less  highly  developed 
lymphocytes  (Strieker,  1881).  Strieker  also  believed  that  the  inter- 
cellular connective  tissues  could,  under  the  influence  of  the  inflam- 
matory process,  revert  again  to  the  embryonal  cells  from  which  they 
were  first  derived.  Whether  Strieker's  views  should  be  accepted  or 
not,  is  still  perhaps  open  to  discussion;  but  pathologists  think  it  miich 
more  certain  at  present  that  a  large  proportion  of  the  round-cell  aggre- 
gation is  derived  from  the  endothelial  cells  lining  the  lymph  spaces 
of  the  perivascular  tissues.  Indeed,  according  to  some  modern  his- 
tologists  (Adami)  there  are  no  such  structures  as  those  formerh' 
described  as  the  fixed  connective  tissue  cells;  for  they  hold  that 
the  only  cells  found  in  the  tissues,  besides  the  lymphocytes  and  the 
wandering  leukocytes,  are  these  very  endothelial  cells,  and  that  the 
spaces  (hypothetical  or  real)  between  them  are  to  be  regarded  as 
lymph  channels. 

In  regard  to  the  origin  of  the  lymphocytes,  Warthin  (1906)  follows 
Ribbert  in  teaching  that  they  are  in  great  part  derived  from  rudi- 
mentary h'mph  nodes  scattered  through  the  tissues. 

The  great  number  of  cells  which  infiltrate  the  tissues  at  this  stage 
of  the  inflammatory  process,  must  not  be  regarded  as  a  mere  aggre- 
gation of  previously  existing  cells.  It  is  probable  that  all  the  cells 
multiply  by  continual  division  and  subdivision  under  the  stimulus  of 
inflammation,  and  that  the  number  of  cells  in  the  part  is  thus  actually 
as  well  as  relatively  increased.  This  fact  is  evident  from  the  mitoses 
which  may  be  seen  in  an  inflamed  area  under  the  microscope. 

Thus  it  is  that  we  find  three  main  types  of  cells  composing  this 
cellular  infiltrate:  (1)  the  emigrated  leukocytes,  which  are  chiefly  poly- 
morphonuclear neutrophiles;  in  the  early  stages  of  inflammation  there 
may  be  a  relative  increase  of  eosinophile  cells;  (2)  the  lymphocytes, 
which  seldom  accumulate  in  great  numbers  until  the  inflammation 
has  existed  for  some  days;  and  (3)  cells  derived  from  the  fixed  con- 
nective tissue  cells  or  from  the  endothelial  cells,  or  from  both.  These 
last  named  cells  are  conveniently  classified  by  Adami  as  fibroblasts 
and  polyblasts,  the  latter  term,  first  employed  by  ^laximow,  being 
intended  to  signify  that  they  are  immature  types  of  various  different 


PATHOLOCY  23 

kinds  of  fully  formed  cells;  while  the  iiaiiie  fihrohliist  is  still  used  to 
describe  that  form  of  iuuuature  coimective  tissue  cell  on  wiiich  the; 
subseciuent  process  of  repair  chiefly  depends. 

When  we  come  next  to  inquire  into  the  object  of  this  round-cell 
infiltration,  we  learn  by  observation  that  a  veritable  warfare  is  going 
on  between  the  bacteria  and  these  cells.  We  observe,  for  instance, 
that  many  of  the  cells  (leukocytes  and  endothelial  cells  in  particular) 
have,  as  it  were,  swallowed  some  of  the  bacteria;  for  we  see  such 
cells  with  one,  two,  three,  or  more  bacteria  in  their  interior.  We 
may  infer  that  some  of  the  bacteria  are  being  killed,  both  from  the 
gradual  diminution  in  their  total  number,  as  well  as  because  the  indi- 
vidual bacteria  no  longer  stain  so  well  as  at  first;  and  we  also  per- 
ceive that  many  of  the  bod}'  cells  succumb,  because  their  nuclei  swell 
up,  their  protoplasm  becomes  cloudy,  they  fail  to  stain,  and  finally 
disintegrate  and  disappear,  while  the  triumphant  bacteria  attack 
other  cells.  This  process,  by  which  the  cells  devour  the  bacteria,  is 
known  as  phagocytosis  (Metchnikoft',  1893),  and  the  cells  which  thus 
act  are  called  phagocytes. 

Moreover,  in  addition  to  the  defence  thus  provided  by  the  cellular 
elements  called  into  action  by  the  irritants  causing  inflammation, 
there  exist  in  the  body  fluids  certain  substances  (anti-bodies)  which 
act  as  very  important  aids  in  the  defence.  In  the  normal  blood- 
plasma  exist  certain  chemical  substances  termed  opsonins  (Wright 
and  Douglas,  1908),  because  they  act  as  caterers  for  the  phagocytes, 
by  preparing  the  bacteria  for  destruction.  Thus  it  has  been  found 
that  though  white  blood  cells  are  active  phagocytes  while  still  sur- 
rounded by  blood  plasma,  they  are  absolutely  indifferent  to  bacteria 
if  deprived  of  plasma.  In  the  fluid  exudate  which  is  produced  during 
the  inflammatory  process  there  are  also  chemical  substances,  known 
as  bacteriolysins  (Nuttall,  1888),  which  are  extremely  destructive  to 
these  causes  of  inflammation;  these  bacteriolysins  are  classified  as 
alexins  (Buchner,  1890),  which  destroy  the  bacteria,  and  antitoxins 
(Behring,  1890),  which  neutralize  the  bacterial  toxins.  It  is  probable 
that  they  are  both  produced  by  disintegration  of  leukocytes.  These 
inflammatory  exudates  have  a  specific  gravity  of  1018  or  higher,  and 
contain  at  least  4  per  cent,  of  albumin;  they  may  be  distinguished 
thus  from  exudates  due  to  venous  stasis,  and  to  those  caused  by 
hydremic  conditions,  the  fluid  in  the  latter  instances  having  a  much 
lower  specific  gravity,  and  containing  less  albumin. 

The  process  of  inflammation,  as  thus  far  described,  comprises 
clinically  what  has  been  termed  the  first  stage  of  inflammation,  or  the 
stage  of  temporary  hypertrophy.  If  at  this  stage  of  the  process  the 
invading  microbes  are  vanquished,  the  parts  return  to  their  normal 
condition  (resolution)  without  passing  through  the  subsequent  stages 
of  inflammation.  If,  on  the  other  hand,  the  strife  is  prolonged,  the 
fluid  exudate  and  the  cellular  infiltrate  increase  in  quantity,  and  the 
product  of  the  second  stage  of  inflammation,  known  as  inflammatory 
lymph,  is  formed  {lymphization,  lymphogenesis .) 


24  INFLAMMATION 

Inflroiniuitori/  h/iiiph  (Hunter,  1794)  is  a  semi-solid,  gelatinous 
substance,  grayish  white  or  slightly  yellowish  in  tint.  Though  found 
at  least  for  a  .short  time  in  every  case  of  inflammation  which  extends 
beyond  the  first  stage,  it  is  best  observed  in  peritoneal  infections, 
and  in  iritis,  in  both  of  which  instances  the  inflammatory  exudate 
occurs  on  a  free  surface.  The  false  membrane  of  diphtheritic  inflam- 
mation is  another  instance  of  lymph  formation.  Lymph  owes  its 
semi-solid,  plastic  character  to  the  fibrin  it  contains.  The  cellular 
elements  are  not  usually  very  numerous  in  the  early  stages  of  its 
formation,  when  the  exudate  is  still  "serous,"  but  as  the  quantity  of 
cells  increases,  fibrin  ferment  is  formed  by  the  destruction  of  some  of 
their  number,  and  this  fibrin  ferment  acting  upon  the  fibrinogen  and 
certain  calcium  salts  already  present  in  the  exudate,  eventually  forms 
fibrin.  Certain  infectious  agents  call  forth  an  abundant  exudation 
of  inflammatory  lymph;  while  others  are  characterized  rather  by  the 
excessive  round-cell  infiltration  produced.  For  example,  peritonitis 
due  to  the  typhoid  bacillus  is  characterized  by  profuse  serous 
exudate;  when  caused  by  the  streptococcus,  or  the  colon  bacullus, 
the  exudate  contains  a  much  larger  proportion  of  cellular  elements, 
and  therefore  more  closely  resembles  typical  inflammatory  lymph. 
Moreover,  fluid  exudation  is  more  abundant  on  surfaces,  and  in 
the  loosely  built  cellular  tissues,  than  in  denser  structures  such  as 
bone. 

Lymph  serves  a  useful  purpose  in  more  ways  than  one,  for  not  only 
does  it  enmesh  the  microorganisms  and  thus  prevent  their  diffusion 
in  the  tissues,  but  it  also  actively  destroys  them  and  their  products 
by  means  of  the  bacteriolysins  already  described.  It  also  prevents 
absorption  of  the  microorganisms  by  protecting  denuded  endothelial 
surfaces.  It  is,  therefore,  to  be  regarded  as  a  valuable  defence  of  the 
body  against  infection,  and  not  as  a  noxious  product  to  be  removed 
by  the  surgeon. 

Lymph  may  be  absorbed,  may  become  organized,  may  become 
converted  into  j^u-s,  or  may  undergo  other  forms  of  degeneration 
(caseous,  calcareous,  etc.).  If  the  lymph  is  absorbed,  its  cellular 
elements  pass  away  again  into  the  neighboring  blood  and  lymph 
streams,  or  remain  as  fibroblasts  to  produce  new  connective  tissue  in 
the  area  of  inflammation.  Where  the  process  of  inflammation  is 
attended  by  coincident  j^roductive  and  absorptive  changes,  in  approxi- 
mately equal  degree,  the  condition  is  described  as  interstitial  absorp- 
tion. This  condition  is  seen  particularly  in  some  forms  of  osteitis. 
In  the  process  of  organization,  which  will  be  described  more  particu- 
larly in  the  section  on  Repair  (p.  29),  these  fibroblasts  pass  through 
various  stages  until  adult  connective  tissue  is  formed.  It  is  very- 
unusual,  however,  for  complete  regeneration  {restitutio  ad  integrum) 
to  take  place;  almost  always  some  of  the  cells  remain  in  an  immature 
state,  while  others  are  converted  into  scar  tissue.  In  certain  specialized 
forms  of  inflammation,  lymph  undergoes  various  forms  of  degeneration, 
as  the  caseous  or  calcareous,  in  tuberculosis;  but  in  all  cases  in  which 


iwrnoLOGY 


the  inflammatory   process  eoMtinues,  1\  iiipli  is  cvciituaily   converted 
into  jms  (siipjuintiioii,  pi/ofinirsi.s). 

Pus  may  be  defined  as  the  pnxhict  of  the  third  sta^e  of  inflannna- 
tion.     By  giving  a  broad  definition  such  as  this,  we  are  i)ermitted. 


6-V--V  : 


'<r'?  ■ 


Fig.  2.— Miliai^-  abscess  in  a  case  of  septic  embolism  of  the  kidney:  a,  leukocytes 
advancing  toward  and  surrounding  b,  a  mass  of  cocci,  in  whose  "^^g^borhood  alU^^^^^ 
of  a  structure  has  disappeared;  c,  renal  opithehum  too  damaged  b^  ^^f.^XrvS^^^^ 
to  take  the  stain;  d.  kidney  tissue  staimng  normally ;e.  vein  from  which  leukocytes  are 
making  their  way  to  the  commencing  abscess.      X  lUU.     (Creen.j 

as  is  pathologically  proper,  to  include  imder  the  term  pus,  not  only 
the  healthy,  laudable  pus  ^vhich  the  older  surgeons  ^ve^e  so  delighted 
to  behold,'  as  an  expression  of  adequate  reaction  on  the  part  of  the 
patient's  tissues;  but  ^ve  may  also  embrace,  under  the  term  pus,  the 


26  IXFLAMMATIOX 

products  of  tuberculous,  syphilitic,  and  siniilar  processes  which,  as 
A(himi  points  out,  "are  identical  witii  the  tissue  dissolution  that 
occurs  in  acute  abscess." 

Pus,  when  examined  under  the  microscope,  is  seen  to  be  composed 
of  cells  and  of  granular  detritus,  more  or  less  homogeneous  in  char- 
acter, floating  in  a  fluid  known  as  the  Liquor  Puris.  Bacteria  usually 
are  present  also.  The  cells  are  the  leukocytes,  lymphocytes,  and  con- 
nective tissue  cells,  which  formerly  constituted  the  round-cell  infiltra- 
tion of  the  earlier  stages  of  the  inflammatory  process;  but  which  have 
been  killed  by  the  bacterial  toxins,  etc.  The  granular  detritus  consists 
of  the  remains  of  the  cellular  elements  and  intercellular  substance 
of  lymph,  which  have  been  disintegrated  by  the  ferments  (peptones, 
etc.)  generated  during  the  warfare  between  the  bacteria  and  their 
toxins  with  the  body  cells  and  their  bacteriolysins.  The  Liquor 
Puris  is  the  slightly  altered  fluid  exudate  already  described.  In  other 
words,  pus  has  been  produced  from  lymph  by  a  species  of  liquefaction 
necrosis. 

If  pus  is  completely  circumscribed  by  the  body  tissues  it  consti- 
tutes an  abscess.  If  it  is  formed  on  the  surface  of  a  part  it  is  said  to  be 
constantly  "discharged."  If  neither  formed  on  a  surface  nor  well 
circumscribed,  but  rather  diffusely  infiltrated  among  the  body  tissues, 
the  pus  is  said  to  form  a  phlegmon;  and  the  inflammation  is  said  to  be 
phlegmonous  in  type.  In  any  case,  there  is  a  certain  surrounding  area 
where  the  strife  between  the  body  tissues  and  the  invading  micro- 
organisms still  continues.  This  area,  when  surrounding  an  abscess, 
was  formerly  spoken  of  as  a  pyogenic  membrane,  because  it  was  believed 
that  pus  was  secreted  in  the  same  way  as  the  secretion  of  a  gland  is 
produced.  If  the  body  tissues  succeed  in  holding  their  own,  and  the 
invasion  comes  to  a  halt,  then  there  is  formed  in  the  area  surrounding 
the  abscess  what  is  known  as  granulation  tissue;  if,  on  the  other  hand, 
the  body  tissues  continue  to  be  destroyed  by  the  bacteria  and  their 
toxins,  then  the  process  is  described  as  ulceration,  provided  the  change 
occurs  on  a  free  surface  (as  on  the  skin  after  burns,  or  in  the  intes- 
tines in  typhoid  fever,  etc.).  For  although,  from  a  pathological 
point  of  view,  the  process  which  occurs  at  the  so-called  pyogenic 
membrane  of  an  abscess  is  identical  with  that  which  occurs  on  a  free 
surface  on  which  pus  is  being  produced  by  ulceration,  yet  the  latter 
term  is  never  applied  to  the  former  process;  we  merely  say  that  the 
abscess  continues  to  increase  in  size. 

Pus  which  exists  in  the  form  of  an  abscess  may  perhaps  be  absorbed, 
under  exceptional  circumstances,  if  the  amount  of  pus  be  very  small. 
When  this  occurs,  the  granulation  tissue  extends  into  the  puriform 
mass,  the  debris  is  taken  up  by  phagocytes,  and  is  gradually  carried 
away  in  the  blood  and  lymph  channels.  In  other  cases,  where  the 
amount  of  pus  is  small,  and  where  the  abscess  is  deeply  situated, 
the  pus  may  become  encapsulated,  by  the  deposition  in  the  surrounding 
granulation  tissue  of  lime  salts,  or  even  by  the  development  of 
extremely   dense  fibrous  tissue.     In  such  cases   the  contained   pus 


s('ri'rh'.\Ti()\  wininrr  hacteria  27 

•gradually  l)e('(nnes  sterile,  hi  all  cases,  however,  in  whieh  tliere  is 
any  ajjpreeiable  amount  of  pus  jjresent,  the  pus  tends  to  seek  an  exit 
for  itself  in  the  direction  of  least  resistance.  When  the  pus  has  once 
discharj^'cd  itself,  the  former  abscess  cavity  will  j^radually  assume  the 
character  of  an  idccraiituj,  or  rather  of  a  (/nutuldfing  surface,  and  the 
process  of  repair  will  be  the  same  in  both  instances — that  of  an 
evacuated  abscess  and  that  of  an  ulcer. 

Role  of  the  Nervous  System  in  Inflammation,  in  the  account  of 
infianunation  so  far  fjiven,  no  mention  has  been  made  of  any  part 
played  by  the  nervous  system.  This  is  so,  because  it  plays  only  a 
very  insignificant  part  in  this  process.  Experiments  have  proved  that 
even  when  the  entire  ner\ous  supply  of  a  part  has  been  cut  off,  the 
phenomena  of  reaction  to  injury,  as  described  above,  occur  without 
api)reciable  difference;  from  which  fact  it  may  be  assumed  either  that 
the  local  vascular  system  is  endowed  with  a  nervous  mechanism  of 
its  own  (which  does  not  appear  to  have  been  proved),  or  that  the 
vascular  changes  seen  in  inflamed  areas  take  place  without  the  inter- 
position of  nervous  action.  According  to  Warthin  (19()Gj,  however, 
it  has  been  demonstrated  experimentally  that  removal  of  the  vaso- 
constrictor influence  accelerates,  while  removal  of  the  vaso-dilator 
influence  retards  inflammatory  reaction.  Too  little  is  known  of  the 
])seudo-inflammatory  changes  which  occur  in  the  various  neuropathies 
for  pathologists  to  speak  with  authority  about  them.  It  is  certain, 
nevertheless,  that  under  certain  circumstances  lesions  of  the  nervous 
system  may  very  greatly  influence  the  course  of  inflammation,  as 
seen  in  the  case  of  bed-sores  in  spinal  diseases,  and  in  certain  so-called 
trophic  lesions. 

Extension  of  Inflammation. — This  occurs  (1)  by  continuity,  as  when 
l)ronchitis  extends  into  the  pulmonary  tissue,  causing  pneumonia; 
or  when  urethritis  extends  into  the  bladder,  producing  cystitis;  (2) 
l)y  contiguity,  as  when  pneumonic  inflammation  extends  to  the  pleura, 
causing  pleurisy;  or  when  peritonitis  developes  from  appendicitis; 
(3)  by  the  lymphatics,  as  when  a  felon  in  the  finger  is  followed  by 
lymphangeitis  and  epitrochlear  or  axillary  lymphadenitis;  or  (4)  by 
the  blood  stream,  as  in  certain  of  the  exanthemata,  and  in  metastatic 
inflammations. 

Terminations  of  Inflammation. — Inflammation  may  terminate  in  two 
ways:  (1)  by  resolution,  a  gradual  return  of  the  part  to  health;  (2) 
by  death  of  the  patient.  It  is  sometimes  said  that  inflammation  may 
terminate  in  the  local  death  of  the  part  aftected ;  but  as  the  surrounding 
parts  will  still  be  the  seat  of  the  inflammatory  process,  or  of  repair, 
until  either  death  or  recovery  terminates  the  disease,  it  is  more  logical 
to  recognize  this  fact  in  our  definition.  The  manifestations  of  the 
local  death  of  a  part  (sloughing,  mortification,  gangrene)  will  be  con- 
sidered in  Chapter  II. 

Suppuration  without  Bacteria. — In  what  has  been  said  above,  it  is 
assumed  that  the  suppuration  described  has  been  caused  by  bacteria; 
and  in  the  immense  majority  of  instances  this  is  the  case.    But  it  should 


28 


INFLAMMATION 


not  be  forgottou  that  other  cheiiiical  forms  of  irritation,  as  well  j)er- 
haps  as  eertaiii  meehaiiieal  irritants,  may  produce  pus,  if  their  action 
is  sufficiently  virulent  or  i)rolonf^e(l.  Hypodermic  injections  of  tur- 
pentine, mercury,  croton  oil,  or  other  sterile  substances,  may  cause 
all  the  usual  phenomena  of  inflammation,  and  this  may  proceed  so 
far  that  a  fluid  will  be  formed,  which  will  l)e  found  to  consist  of  the 
disintegrated  products  of  tissue  metabolism,  and  which  will  be  indis- 
tinguishable from  pus  as  described  above,  except  for  the  facts  that  no 
bacteria  will  be  present,  and  no  phagocytosis  will  be  evident.  It  is 
(luite  apparent,  nevertheless,  that,  even  in  such  cases,  the  round-cell 
infiltration,  which  succeeds  to  the  early  hyperemia  and  congestion, 
has  been  producefl  by  chemotactic  action  on  the  part  of  the  irritant, 
and  that  the  accumulated  cells  and  tissue  fluids  in  the  process  of 
their  reaction  are  converted  into  substances  which  if  not  technically 
bacteriolysins,  are  some  other  form  of  antibodies  none  the  less  useful 
for  the  defence  of  the  organism. 

Nor  should  it  be  assumed,  on  the  other  hand,  in  every  case  in  which 
inflammation  is  produced  by  bacteria,  that  the  process  necessarily 
will  extend  to  the  stage  of  suppuration.  In  very  many  cases  in  which 
bacteria  are  present,  the  reaction  on  the  part  of  the  body  tissues  is 
sufficient  to  repel  or  to  conquer  the  foe  before  pus  is  formed;  but  it 
is  much  more  usual  for  this  happy  termination  of  the  process  to  occur 
when  the  causes  of  the  inflammatory  reaction  are  sterile.  This  is 
well  seen  in  the  usual  course  pursued  by  clean  wounds. 


Fig.  3.— Staphylococci  in  pus.      X  1000. 
(Friinkel  and  Pfciffer.) 


Fig.  4.— Streptococci  in  pus.      X  1000. 
(Frankol  and  Pfeiffer.) 


Pyogenic  Bacteria.  —  Certain  microorganisms  are  habitually  pyo- 
genic; certain  others  produce  pus  only  under  special  circumstances; 
while  a  few  varieties  have  never  been  known  to  cause  sui)puration. 
It  is,  therefore,  possible  to  classify  pathogenic  bacteria  in  the  follow- 
ing manner:  (1)  Microdrganisms  characteristically  leading  to  pus  and 
abscess  formation — Staphylococcus,  Streptococcus  pyogenes,  Bacillus 


RKl'MR  _  29 

antliracis.  Of  tlioso,  tlio  \arieti(\s  of  tlic  stapliylocoociis  (Iciioted  hy 
tlie  suffixes  aureus,  (tlbus,  and  cltreus,  and  jijciu'rically  included  under 
tlie  term  IMiorococcus  pyogenes,  are  those  which  are  especially  asso- 
ciated with  acute,  well-locali/ed  abscesses;  they  are  found  in  felons, 
furuncles,  carhinicles,  acne,  some  cases  of  empyema,  and  certain 
forms  of  periosteitis,  osteomyelitis,  etc.  The  streptococcus,  on  the 
other  hand,  is  associated  with  spreadin<ji:  infections,  such  as  diffuse 
cellulitis,  erysipelas.  lymphaiifi;eitis;  certain  forms  of  osteomyelitis, 
peritonitis,  etc.  The  Bacillus  antliracis  is  the  cause  of  a  specific 
disease,  which  will  he  describeil  in  Chapter  111.  (2)  Those  causing 
suppuration  ouly  under  exceptional  circumstances — Pneumococcus, 
Bacillus  typhosus,  Bacillus  coli  communis,  Bacillus  pyocyaneus, 
(lonococcus,  Jiacillus  tuberculosis,  etc.  (8)  Those  which  are  never 
known  to  cause  the  j'orination  of  pus — as  Bacillus  tetani. 

Pathological  Summary. — The  first  action  of  an  irritant  when  intro- 
duced into  the  tissues  is  chemotactic  in  nature;  this  influence  extends, 
without  the  aid  of  the  nervous  system,  to  the  endothelial  aiKl  other 
connective  tissue  cells  lying  in  the  perivascular  tissues;  it  also  extends 
to  the  cells  of  the  vascular  endothelium,  and  even  to  the  white  cells 
of  the  circulating  blood.  The  effect  of  this  positive  chemotaxis  is  to 
slow  the  blood  current  and  to  cause  the  endothelial  cells  of  the  blood- 
vessels to  acquire  agglutinative  properties.  As  a  result,  hyperemia, 
and  later  congestion  is  produced;  margi nation,  followed  by  migration 
of  leukocytes,  occurs;  exceptionally  diapedesis  of  the  red  blood  cells 
also  is  present.  Round-cell  infiltration  is  produced  in  this  way,  as 
well  as  by  the  multi])lication  of  those  cells  already  present  in  the 
inflamed  part.  This  constitutes  the  first  stage  of  infiammation,  that 
of  Temporary  Hypertrophy.  The  warring  hosts  have  been  assembled 
and  the  battle  between  the  invading  microorganisms  and  the  phago- 
cytes is  next  begun;  the  fluid  exudate  aids  the  cells  in  the  fight  by 
means  of  its  bacteriolysins.  Lymph  is  thus  produced,  constituting 
the  second  stage  of  inflammation.  Owdng  to  the  progressive  destruc- 
tion of  leukocytes  and  other  cells,  ferments  are  produced,  which 
liquefy  the  lymph,  converting  it  into  pus;  thus  by  pyogenesis,  the 
third  and  last  stage  of  infiommation  is  reached.  In  the  surrounding 
tissues  progressive  destruction  {ulceration)  continues,  or  gradual  repair 
{granulation)  terminates  the  process. 

Repair.  —  It  has  been  pointed  out  (p.  28)  that  the  inflammatory 
process  may  be  terminated  at  any  stage  of  its  course  as  a  result  of  the 
defensive  powers  of  the  organism  overcoming  the  invasion  of  the 
irritant  which  was  the  primary  cause  of  the  inflammation.  Speaking 
generally,  we  may  recognize  three  more  or  less  distinct  ways  in  which 
repair  occurs,  corresponding  to  the  three  stages  of  inflammation 
described. 

1.  If  the  process  of  inflammation  is  arrested  during  the  stage  of 
temporary  hypertrophy,  before  any  exudate  has  been  formed,  the 
migrated  leukocytes  and  other  phagocytes,  having  destroyer!  the  bac- 
teria, and  being  no  longer  attracted  by  the  chemotactic  influence  of 


30  INFLAMMATION 

the  imaders,  resume  their  normal  functions  and  return  to  their  usual 
spheres;  the  white  blood  cells  re-enter  the  capillaries,  the  lymph  cells 
swim  away  in  the  lymph  stream,  and  the  site  of  former  inflammation 
can  no  longer  be  distinguished  from  the  surrounding  tissues;  it  is  said 
to  have  undergone  regeneration,  complete  repair,  restitutio  ad  integrum. 

2.  If  the  process  of  inflammation  is  arrested  during  the  stage  of 
lymph  formation,  complete  regeneration  cannot  take  place,  because 
the  tissues  are  not  capable  of  removing  completely  the  results  of  the 
warfare  betAveen  the  irritant  and  themselves.  Some  of  the  cellular 
elements  may  pass  away  again  in  the  blood  and  lymph  streams,  but 
almost  without  exception  a  goodly  number  will  remain  in  the  pre- 
viously inflamed  part,  will  become  converted  into  fibroblasts,  and 
eventually  will  form  scar-tissue.  It  does  not  seem  to  be  certainly 
known  whether  leukocytes  ^an  become  converted  into  fibroblasts; 
but  there  is  no  doubt  that  most  of  the  fibroblasts  are  produced  from 
endothelial  or  fixed  connective  tissue  cells.  Fibroblasts  are  elongated, 
caudate,  or  spindle-shaped  cells,  occasionally  stellate  in  form. 

The  area  of  inflammatory  exudation  becomes  vascularized  by  the 
out-growth  of  capillaries  from  the  surrounding  bloodvessels.  These 
new  capillaries  grow  as  solid  sprouts;  and  these  solid  processes,  grow- 
ing out  into  the  exudate  of  inflammatory  lymph,  either  meet  other 
similar  out-growths,  or  become  attached  to  a  neighboring  capillary, 
thus  forming  more  or  less  distinct  loops;  these  loops  subsequently 
become  hollowed  out,  and  the  channels  so  formed  are  filled  by  blood 
from  the  surrounding  capillaries.  As  the  process  of  repair  goes  on, 
the  fibroblasts  become  more  and  more  fibrous  in  character  "  until  the 
cell  is  represented  by  a  meagre,  attenuated  nucleus,  with  but  a  trace 
of  cytoplasm,  lying  surrounded  by  fibrils — white  connective  tissne." 
(Adami.)  The  conversion  of  the  fibroblasts  into  white  connective 
tissue  and  the  invasion  of  the  inflammatory  exudate  by  the  capillary 
loops  go  on  hand  in  hand;  the  tissue  thus  formed  is  known  as  granu- 
lation tissne;  and  when  the  process  occurs  on  a  free  surface  the  capil- 
lary loops  form  the  so-called  granulations.  The  granulation  tissue  is 
at  first  highly  vascular  and  red;  as  the  more  fully  de\-eloped  scar- 
tissue  is  formed,  granulation  is  succeeded  by  cicatrization,  and  the 
capillaries  are  squeezed  out  of  existence  as  the  process  of  contraction 
in  the  scar-tissue  continues.  Thus  a  scar  which  at  first  is  red  and 
angry  in  appearance,  eventually  may  become  white,  glistening,  and 
depressed  below  the  surrounding  tissues.  The  area  of  previous  inflam- 
mation, which  during  the  height  of  the  inflammatory  process  Avas 
swollen  and  tense,  thus  finally  comes  to  occupy  less  space  than  in 
health. 

3.  If  the  process  of  inflammation  has  progressed  to  the  stage  of 
suppuration,  then  in  almost  all  cases  it  is  necessary  for  the  pus  to  be 
discharged  by  the  rupture  of  the  abscess  before  rapair  can  occur. 
It  is  extremely  unusual  for  pus  to  be  absorbed  or  for  scar-tissu6  to  be 
formed  unless  the  abscess  has  first  been  converted  into  an  ulcer. 
Repair  in  this  instance,  therefore,  is  best  studied  as  it  occurs  on  a 


syMPTO}rs  31 

free  surface,  and  is  tlie  same  as  tliat  wliich  occurs  in  the  healing  of 
an  ulcer  (p.  53). 


/ 


V 


-- <r 


Fig.  5. — Fibroblasts  and  granulation  tissue.  Section  of  a  cutaneous  granulation: 
V  v',  new-formed  capillaries  sprouting  from  depth  of  granulation  and  accompanied  by 
connective  tissue  cells  (c)  and  leukocytes  (/).  A  layer  of  fibrin  (/)  covers  the  surface 
of  the  granulation.  Between  the  superficial  layers  of  the  fibrin  are  seen  large  connec- 
tive tissue  cells  (d')  springing  from  the  granulation  (rf).      X  300.      (Cornil  and  Ranvier.) 

Symptoms. — The  symptoms  of  inflammation  are  local  and  general 
(or  constitutional).  x\mong  the  latter  are  the  usual  signs  of  fever, 
attended  frequenth'  b}'  quickening  of  the  pulse  and  respiration  rate; 
headache,  flushing  of  the  face,  brightening  or  injection  of  the  eyes, 
and  perhaps  delirium  at  night;  anorexia,  with  furred  tongue,  and 
sometimes  nausea;  dry,  hot  skin;  thirst;  usually  the  bowels  are 
constipated,  and  the  urine  high  colored  and  lessened  in  quantity. 
Under  constitutional  symptoms  it  may  also  be  proper  to  include 
leukocytosis,  an  increase  in  the  number  of  leukocytes  present  in  the 
circulating  blood.  This  leukocytosis  is  present  in  almost  all  acute 
inflammations;  it  is  called  forth  by  the  chemotactic  powers  of  the 
irritant,  whose  diifusible  toxins,  when  they  obtain  admission  to  the 
circulating  blood,  are  carried  to  the  bone  marrow  and  other  portions 
of  the  body  whence  leukocytes  are  derived,  and  thus  stimulate  the 
production  of  leukocytes.  In  a  few  diseases,  not  usually  classified 
as  inflammations,  the  influence  of  negative  chemotaxis  is  manifested 
in  the  diminution  of  the  number  of  circulating  leukocytes  ijiypo- 
leukocytosis,  leukopenia).  Among  such  diseases  typhoid  fever  and 
tuberculosis  are  the  most  important.  What  were  formerly  called 
critical  discharges  may  occur  either  at  the  approach  of  convalescence, 


32  INFLAMMATION 

or  upon  an  unfavorable  change  in  the  patient's  general  condition. 
These  discharges  are  described  as  diarrhea,  diuresis,  profuse  sweating, 
and  sometimes  hemorrhages  from  the  mucous  membranes.  Their 
significance,  as  well  as  the  probable  causes  and  the  pathology  of 
inflammatory  fever,  will  be  considered  in  Chapter  II.  When  the 
inflammation  is  slight,  constitutional  symptoms  may  be  trivial  or 
entirely  absent;  when  occurring  in  robust,  healthy  indi\iduals,  the 
sthenic  type  of  fever  is  seen;  when  in  the  weak  and  debilitated,  or, 
when  the  inflammation  is  overwhelming,  e^•en  in  the  strong,  a  typhoid 
(asthenic,  adynamic)  type  of  fever  will  result. 

The  local  symptoms  of  inflammation  have  been  described  from  the 
time  of  Celsus  under  the  terms  (1)  Rubor,  or  redness;  (2)  Tumor,  or 
swelling;  (3)  Valor,  or  heat;  and  (4)  Dolor,  or  pain;  while  to  these 
classical  symptoms  has  been  added  that  of  (5)  Functio  Lcpsa  (modifi- 
cation of  function) ;  and  again  a  sixth  symptom  (6)  Modification  of 
nutrition. 

One  or  more  of  these  local  symptoms  may  be  present  without  the 
disease  constituting  inflammation;  it  may  be  impossible  to  elicit 
evidences  of  one  or  more  of  these  symptoms,  even  when  inflammation 
is  present.  Friction  of  the  skin  may  produce  a  temporary  hyperemia, 
accompanied  by  redness  and  heat,  without  true  inflammation  being 
present;  the  erectile  tissues  furnish  another  example  where  the'  pres- 
ence of  one  or  two  symptoms  alone  is  not  sufficient  to  qualify  the 
affection  as  inflammation.  On  the  other  hand,  it  will  be  impossible 
in  many  deep-seated  inflammations  (meningitis,  pleurisy,  etc.)  to 
detect  redness,  and  sometimes  impossible  to  demonstrate  swelling, 
even  though  no  doubt  can  exist  that  inflammation  is  actually  present. 
Some  of  these  local  symptoms  are  more  manifest  in  certain  tissues, 
organs  or  localities,  than  in  others.  Thus  conjunctivitis,  periosteitis, 
orchitis,  are  especially  painful;  cellulitis  is  preeminently  characterized 
by  swelling;  alteration  of  function  is  more  evident  the  more  highly 
specialized  the  tissue  or  organ  affected  (compare  iritis  with  tonsillitis; 
neuritis  with  dermatitis,  etc.);  while  in  the  cornea  and  in  cartilage 
alterations  of  nutrition  may  be  the  only  demonstrable  change. 

Redness  is  nearly  universally  present  in  superficial  inflammations. 
It  is  primarily  due  to  the  hyperemia  and  congestion  of  the  inflamed 
part.  Early  in  the  course  of  the  disease  the  redness  is  bright,  flaming, 
intense,  as  in  erysipelas;  later  it  may  become  bluish  or  almost  purple, 
as  suppuration  or  gangrene  impends.  It  is  not  sharply  outlined  in 
ordinary  forms  of  inflammation,  but  blends  away  in  the  surrounding 
tissues  so  that  it  is  often  impossible  to  define  its  exact  limits.  The 
redness  due  to  inflammation  disappears  when  the  finger  is  pressed 
upon  the  inflamed  spot.  The  rapidity  with  which  the  redness  returns 
after  the  removal  of  pressure  gives  a  fair  idea  of  the  activity  of  the 
circulation;  if  suppuration  or  gangrene  is  threatening  the  circulation 
is  sluggish.  It  should  not  be  forgotten  that  a  sluggish  circulation  may 
be  due  to  organic  disease  of  the  heart,  and  that  this  will  modify  the 
local  manifestations  of  inflammation  even  in  an  early  stage. 


SYMI'TOMS  33 

Snrlling  is  due  to  the  hyperemia,  to  the  round-eell  infiltrate,  and 
to  the  Hiiid  exudate  charaeteristie  of  inflaniniation.  Thus  tissues 
where  exudation  is  profuse  (eyelid,  scrotum,  and  subcutaneous  tissues 
generally)  show  more  alteration  of  form  than  do  such  structures  as 
hone  or  cartihij,'e.  Blehs  frequently  form  in  the  skin  as  the  result  of 
effusion  of  serum  beneath  the  epidermis;  this  is  seen  especially  in  burns 
and  severe  contusions,  such  as  those  accompanying  fractures  or  dis- 
locations. Swelling  is  beneficial  in  so  far  as  it  tends  to  deplete  the 
overloaded  capillaries;  it  may  be  harmful  by  its  tendency  eventually 
to  block  the  circulation  and  thus  favor  sloughing  or  gangrene.  It 
may  endanger  life  by  occluding  mucous  channels — such  as  the  glottis, 
the  bile  ducts,  the  appendix;  or  by  compressing  the  urethra  when 
the  swelling  occurs  in  the  perineum.  The  swelling  of  the  early  stages 
of  inflammation  is  tense,  and  rather  elastic  to  the  touch;  later  it 
becomes  dense  and  brawny  if  due  to  exudate  which  is  coagulable, 
or  edematous  and  soft  if  due  to  non-coagulable  effusion.  When  an 
inflamed  area  begins  to  "pit  on  pressure,"  it  is  often  indicative  of  the 
presence  of  pus. 

Heat  in  an  inflamed  part  usually  is  appreciable  to  the  hand,  when 
compared  with  a  neighboring  or  similar  part  of  the  patient's  body 
which  is  not  inflamed.  In  artliritis  the  affected  joint  feels  hot,  while 
the  corresjjonding  joint  does  not.  Local  heat  is  doubtless  produced 
in  large  part  by  the  numerous  chemical  reactions  constantly  occurring 
in  the, inflamed  area.  The  toxins,  bacteriolysins,  ferments,  etc.,  are 
all  of  them  produced  by  forms  of  biochemical  activity  which  thus  far 
are  little  understood.  The  mere  hyperemia  of  the  part  is  not  suffi- 
cient to  account  for  the  heat  present.  Yet  the  local  temperature  is 
rarely  if  ever  higher  than  that  of  the  circulating  blood;  but  it  is  rela- 
tively higher  than  is  that  of  surrounding  parts,  because  there  is  more 
blood  in  the  inflamed  part,  and  especially  near  the  surface  of  the 
inflamed  part,  than  in  surrounding  non-inflamed  parts;  moreover  the 
temperature  of  the  circulating  blood  may  be  higher  than  normal 
(inflammatory  fever),  but  its  abnormal  heat  is  derived  from  the  local 
changes,  not  the  local  heat  from  a  primary  increase  in  the  temperature 
of  the  blood.  The  local  heat  is  greatest  at  the  height  of  the  inflam- 
mation; as  the  disease  progresses  the  local  temperature  falls,  and  when 
suppuration  occurs  it  is  no  longer  above  that  of  surrounding  parts. 
In  the  case  of  gangrene,  the  temperature  of  the  mortified  part  naturally 
becomes  subnormal. 

Pain  due  to  the  inflammatory  process  is  caused  by  tension,  from  cel- 
lular infiltration  and  fluid  exudation,  producing  pressure  on  the  terminal 
nerve  fibres  of  the  part.  The  pain  is  much  less  in  tissues  which  admit 
of  much  swelling  than  in  fibrous  tissues  (felon)  or  bone  (periosteitis) ; 
and  it  may  be  relieved  In-  allowing  the  escape  of  the  eft'usion  through 
incisions.  Inflammation  in  a  part  devoid  of  sensory  nerves  is  not 
attended  by  pain.  Referred  pain  is  to  be  explained  on  anatomical 
grounds,  and  is  due  either  to  pressure  on  a  ner\e  trunk,  causing  pain 
in  its  terminal  fibres  fas  in  the  case  of  pain  in  the  knee  due  to  pressure 


34  INFLAMMATION 

on  the  obturator  nerve  at  the  hip) ;  or  to  overstimulation  of  a  nerve 
causing  an  overflow  of  painful  sensations  into  neighboring  nerves 
derived  from  the  same  spinal  segment:  thus  gall-bladder  disease  may 
cause  pain  in  the  shoulder  through  the  spinal  nerves  derived  from  the 
same  segment  as  that  from  which  the  pneumogastric  takes  its  origin; 
pain  in  the  testicle  follows  disease  of  the  kidney  or  ureter;  inflam- 
mation of  the  neck  of  the  bladder  is  accompanied  by  pain  in  the  head 
of  the  penis;  pleurisy  may  cause  cutaneous  hyperalgesia  of  the  abdo- 
men. The  pain  felt  in  an  inflamed  part  varies  with  the  tissue  affected : 
in  the  skin  (insect  bites,  etc.)  or  mucous  membranes  (conjunctivitis, 
hemorrhoids,  etc.)  it  is  manifested  as  an  itching  or  scalding  sensation; 
in  serous  and  synovial  cavities  it  is  felt  as  a  lancinating  or  stabbing 
pain  (peritonitis,  pleurisy,  synovitis);  in  fibrous  tissues  it  is  dull, 
aching,  or  boring  (periosteitis,  etc.).  Pain  usually  is  greatest  during 
the  height  of  inflammation;  if  the  nervous  structures  are  poisoned 
by  toxins,  the  pain  may  be  slight ;  sudden  cessation  of  pain  frequently 
is  indicative  of  gangrene  (appendicitis,  strangulated  hernia).  At  the 
approach  of  suppuration,  the  pain  assumes  a  throbbing  character: 
mortification  is  frequently  announced  by  a  burning  pain. 

Tenderness  on  iiressure  is  an  important  modification  of  the  sensa- 
tion of  pain,  and  may  persist  when  pain  has  been  lost  through  gan- 
grene of  the  inflamed  part.  Thus  even  when  the  spontaneous  pain 
of  appendicitis  has  ceased  on  the  occurrence  of  gangrene,  tenderness 
may  still  persist  in  the  surrounding  area  of  the  peritoneum.  If  pain 
is  present  in  a  part  without  local  tenderness,  the  pain  is  referred  pain, 
and  the  seat  of  inflammation  is  elsewhere.  I  have  never  seen  both 
pain  and  tenderness  present  locally  in  an  uninflamed  part,  unless  the 
tenderness  w^as  a  mere  cutaneous  hyperalgesia.  ]\Iistaking  the  latter 
once  for  a  sign  of  local  disease,  I  removed  a  normal  appendix  vermi- 
formis  from  a  youth  who  twenty-four  hours  later  developed  symptoms 
of  pleuropneumonia. 

Muscular  rigidity  is  due  to  voluntary  or  involuntary  contraction 
of  the  muscles  governing  the  movements  of,  or  protecting  an  inflamed 
part.  Involuntary  contraction  is  due  to  the  impulse  being  referred 
to  motor  instead  of  sensory  nerves,  as  is  the  case  in  referred  pain. 

Impaired  function  is  more  noticeable  the  more  highly  developed 
the  inflamed  structures.  It  is  an  old  maxim  that  in  inflammation  the 
first  functional  change  is  always  in  the  direction  of  excess.  Parts  which 
possess  normally  very  little  sensation  may  become  acutely  painful; 
glandular  structures  produce  an  abundant,  though  disordered  secre- 
tion; muscular  structures  contract  irregularly  and  spasmodically, 
as  in  fractured  limbs,  and  in  inflammation  of  the  hollow  viscera 
(appendix,  stomach,  gall-bladder,  urinary  bladder,  etc.).  The  special 
senses  are  even  more  affected:  scintillations  of  light  and  photo- 
phobia attend  inflammatory  affections  of  the  eye;  tinnitus  aurium 
is  annoying  in  certain  diseases  of  the  ear;  perversions  of  taste,  of 
smell,  etc.,  are  common  in  affections  of  the  tongue  and  nose.  At  a 
later  stage  of  inflammation  the  function  of  a  part,  instead  of  being 


TREATMENT  OF  INFLAMMATION  35 

stimiilated,  is  depressed  or  altogether  abolislicd:  during  the  height  of 
nephritis,  the  urine  is  suppressed,  and  when  the  secretion  is  restorecl 
its  nature  may  he  markedly  and  i)ermanently  altered. 

Modification  of  Nuirition. — The  temporary  hypertrophy  seen  in  the 
earlier  stages  may  never  be  recovered  from;  scars  may  become  keloids; 
callus  may  never  be  absorbed  entirely;  bones,  the  seat  of  osteo- 
myelitis, may  remain  permanently  thickened;  lymph-edema  may  suc- 
ceed to  cellulitis.  Atrophy,  on  the  contrary,  may  take  the  i)lace  of  a 
return  to  the  normal;  in  coxalgia  the  head  of  the  femur  may  disappear 
by  interstitial  absorption. 

Chronic  Inflammation. — It  is  an  arbitrary  thing  to  classify  inflam- 
mation as  acute,  subacute,  and  chronic.  The  former  has  })een  described ; 
the  latter  is  an  inflammatory  affection  of  long  duration,  and  charac- 
terized by  slight  or  moderate  reaction.  Subacute  is  a  mean  between 
the  two.  The  error  should  not  be  made  of  classing  with  chronic  inflam- 
mation certain  results  of  previous  inflammations,  which  consist 
essentially  in  the  formation  of  scar  tissue  or  dift'use  fibrosis.  It  is 
better  to  speak  of  such  changes  as  old  inflammations;  and  to  limit 
the  term  chronic  inflammation  to  a  process  of  reaction  which  is  still 
going  on,  even  if  very  sluggishly.  For  strictly  speaking  a  chronic 
inflammation  is  merely  one  in  which  the  irritant  is  weak,  but  con- 
tinues long  in  action;  in  which  only  a  slight  reaction  is  produced,  and 
in  which  some  factor  prevents  healing.  This  reaction  is  not  wont  to 
go  beyond  the  stage  of  formation  of  granulation  tissue.  The  attacking 
force  and  the  repelling  garrison  are  so  equally  matched  that  neither 
can  well  overcome  the  other;  cell  accumulation  is  marked,  but  phago- 
cytic power  is  slight;  exudation  is  slight;  tendency  to  suppuration  is 
si  ght.  Such  inflammations  are  seen  in  the  case  of  the  infect  ions 
granulomas.  When  healing  occurs,  the  scar-tissue  formed  is  propor- 
tionate to  the  previous  hyperplastic  condition. 

The  symptoms  are  similar,  but  less  in  degree,  than  those  seen  in 
acute  inflammation.  As  might  be  expected  from  what  is  known  of 
the  pathology  of  chronic  inflammations,  swelling  is  the  most  char- 
acteristic s^aiiptom.  Pain  usually  is  moderate,  but  may  be  intense, 
especially  in  bones  and  joints.  Redness  is  slight.  Heat  often  cannot 
be  detected. 

Treatment  of  Inflammation. — Prophylaxis. — The  consideration  of 
the  treatment  of  inflammation  involves  first  of  all  a  study  of  the 
means  of  prevention.  Inflammation,  even  when  it  has  once  com- 
menced, frequently  may  be  aborted  by  the  prompt  removal  of  the 
cause.  If  the  insult  to  the  tissues  be  due  to  a  foreign  body,  the  removal 
of  the  foreign  body  will  prevent  the  reaction  which  its  prolonged  pres- 
ence undoubtedly  would  provoke.  The  removal  of  a  cinder  from  the 
eye  may  pre^'ent  the  development  of  conjunctivitis;  that  of  a  splinter 
from  the  finger  may  prevent  the  formation  of  a  felon.  In  some 
diseases  and  in  certain  parts  of  the  body,  prompt  excision  or  amputa- 
tion of  the  diseased  member  will  prevent  the  development  of  an  inflam- 
mation which  might  proNe  fatal.    Prompt  amputation  of  a  hopelessly 


36  INFLAMMATION 

mangled  limb  will  prevent  gangrene  and  subsequent  infection;  imme- 
diate removal  of  an  inflamed  appendix  will  abort  the  disease  by 
removing  its  cause,  before  the  inflammatory  reaction  has  spread  to 
the  peritoneum. 

As  bacteria  are  the  most  frequent  causes  of  inflammation,  this  may 
be  most  surely  guarded  against  by  preventing  the  entrance  of  bacteria 
into  wounds,  or  by  removing  them  or  killing  them  after  their  entrance 
has  been  effected.  The  condition  of  the  tissues  when  infected  by 
bacteria  is  known  as  Sepsis;  Asepsis  is  the  condition  when  no  bac- 
teria are  present;  Antisepsis  is  a  method  by  which  bacteria  are  com- 
bated by  certain  chemicals  termed  Antiseptics.  The  constant  use  of 
antiseptics  on  living  tissues  is  open  to  the  objection  that  the  tissues 
are  injured  as  well  as  the  bacteria;  though  it  is  true  that  usually  the 
injury  to  the  tissues  is  insignificant.  ^Yhen  once  bacteria  have  gained 
entrance  to  the  tissues  there  are  only  two  ways  by  which  their  destruc- 
tion can  be  effected;  the  first  is  by  the  natural  reaction  of  the  tissues 
which  we  call  inflammation,  and  which  may  be  assisted  artificially 
by  the  use  of  sera  or  vaccines  (p.  44),  the  other  method  is  by  the 
direct  introduction  of  antiseptics  into  the  open  wound. 

It  has  been  learned  by  long  and  costly  experience  that  pathogenic 
bacteria  are  everj'where  present  in  civilization,  and  that  mere  ordi- 
nary cleanliness  will  not  suffice  to  exclude  them.  They  are  not 
present  in  the  air,  however,  unless  this  be  dust  laden,  in  number 
sufficient  to  be  harmful;  they  are  carried  from  place  to  place  only 
by  actual  contact  of  instruments,  dressings,  etc.,  on  which  they  may 
have  lodged.  They  may  be  killed  by  boiling,  or  by  dry  heat  at  a 
sufficiently  high  temperature;  and  the  instruments,  dressings,  etc., 
thus  sterilized  will,  therefore,  be  aseptic.  But  unless  the  surgeon's  or 
the  nurse's  hands  be  also  aseptic,  the  mere  momentary  contact  of 
such  hands,  or  of  any  other  unsterilized  thing,  with  the  aseptic 
instruments  or  dressings,  will  at  once  be  liable  to  contaminate  them, 
and  they  will  again  become  septic — to  what  degree  no  one  can  tell. 
Neither  the  hands  of  the  surgeon  nor  the  skin  of  the  patient  can  be 
sterilized  by  boiling  or  by  dry  heat;  but  by  thorough  washing  in 
soap  and  water,  and  by  the  use  of  certain  chemicals,  practically  all 
the  bacteria  present  on  the  surfaces  so  treated  may  be  removed; 
and  those  still  remaining  may  be  remlererl  so  inert  that  they  will  be 
incapable  of  exciting  inflammation.  As  an  additional  precaution, 
boiled  gloves  of  thin  rubber  may  be  worn. 

The  introduction  of  the  practice  of  asepsis  and  antisepsis  in  surgery 
dates  from  1S07,  when  Lister  published  his  first  observations  on  the 
antiseptic  method  of  wound  treatment;  his  practice  was  founded  on 
and  confirmed  by  the  researches  of  Pasteur,  concerning  fermentation 
and  putrefaction;  and  although  the  science  of  bacteriology  may  be 
said  to  date  from  the  discovery  of  the  Bacillus  tuberculosis  by  Koch, 
in  1SS2,  the  great  advances  made  in  modern  surgery  undoubtedly  owe 
their  existence  to  Lister's  initiative.  When  no  antiseptics  were  used, 
the  healing  of  wounds  was  tedious  in  the  extreme,  and  the  inflammatory 


LOCAL  REMEDIAL  THE  AT  ME  XT  .',7 

reactinii  practically  always  exteiuled  to  the  stage  of  pus  forniation. 
SiiKf  the  introduction  of  the  i)ractice  of  asepsis  and  .antisepsis,  sur- 
geons have  heconie  accustomed  to  jiaving  their  wounds  heal  with 
little  or  with  no  apparent  inflammatory  reaction.  Oilier  reported  a 
mortality  of  80  per  cent,  from  excisions  of  the  knee  hefore  adopting 
the  antiseptic  method;  after  adopting  this  method,  his  mortality 
fell  to  14  per  cent.' 

Asepsis  is  generally  acknowledged  to  he  letter  than  antisepsis, 
whenever  it  is  practicable.  In  operative  wounds  asepsis  is  usually 
possible;  but  when  the  wound  is  infected  before  it  comes  under  the 
surgeon's  care,  it  is  usually  safer  to  adopt  antiseptic  principles. 
Wounds  ant]  wnuiid  treatment  are  discussed  in  Chapter  VI. 

Cure  of  Inflammation. — The  remedial  treatment  of  inflammation 
may  be  divided  into  the  Local  and  the  Constitutional.  Under  the 
former  head  are  included  such  methods  as  Rest  of  the  inflamed 
part;  its  Position;  the  use  of  Heat  and  Cold;  Xarcotics  and  Counter- 
irritants;  Bleeding,  Leeching,  etc.;  Incisions  and  Operations;  Compres- 
sion; Active  and  Passive  Congestion;  Massage,  etc.  Under  the  latter 
will  be  considered  Constitutional  Rest;  Diet;  Drugs;  and  the  curative 
use  of  varrines,  sera,  and  opsonins. 

Local  Remedial  Treatment. — Rest  of  the  inflamed  part  is  desirable 
to  decrease  the  hyperemia  and  congestion,  when  these  are  excessive; 
to  lessen  the  cellular  infiltrate  and  the  exudation;  and  to  enable  all 
the  forces  of  nature  to  be  exerted  in  overcoming  the  causes  of  disease, 
instead  of  expending  their  strength  in  unnecessary  physiological  pro- 
cesses which  functional  use  of  the  part  would  entail.  Rest  in  bed  is 
indispensable  in  a  great  many  inflammations  of  the  head,  trunk,  and 
lower  extremities.  Rest  may  be  procured  by  the  use  of  splints,  when 
these  are  sufficient,  as  in  many  fractures,  wounds  of  the  extremities, 
felons,  etc.;  by  gypsum  cases  when  rest  for  a  longer  period  is  desirable, 
as  in  inflammations  of  certain  joints;  by  bandages,  or  strapping  icith 
adhesive  plaster,  as  in  fractures  of  the  ribs,  slight  sprains,  etc.  P  inally 
rest  may  be  procured  by  position. 

Position  is  of  importance,  because  neglect  to  elevate  an  inflamed 
part,  and  thus  to  prevent  or  lessen  congestion,  may  markedly  increase 
the  pain;  may  favor  the  occurrence  of  suppuration  or  sloughing; 
or  invite  gangrene  by  interference  with  the  natural  circulation  of  the 
part.  Carrying  the  hand  in  a  sling;  keeping  the  foot  elevated  on  a 
stool;  or  even  going  to  bed  for  a  time,  will  each  of  them  prove  of 
benefit  in  special  cases. 

Cold  is  an  invaluable  agent  in  the  treatment  of  inflammation  in  its 
early  stages.  It  is  anesthetic,  benumbing  the  part  and  lessening  pain; 
it  constricts  the  bloodvessels,  decreasing  the  hyperemia,  and  some- 

1  It  is  true  that  the  late  Prof.  Ashhurst  (1895),  in  a  series  of  84  excisions  of  the 
knee-joint,  had  a  mortaUty  of  only  8. -3  per  cent.,  the  series  extending  through  both 
pre-antiseptic  and  antiseptic  periods;  yet  it  is  to  be  noted  that  he  uniformly  used 
scrupulous  cleanhness,  and  virtual  anti.septics  (turpentine,  alcohol,  potassium 
permanganate)  even  before  adopting  Lister's  principles  of  wound  treatment. 


38  INFLAMMATION 

times  prcventino:  excessive  effusion;  and  it  is  not  impossible  that  ; 
lessens  the  physiological  activities  of  a  part,  thus  promoting  rest. 
It  probably  lessens  peristalsis  in  cases  of  peritonitis.     Its  chief  use, 
however,  is  in  inflammations  of  traumatic  origin — wounds  of  the  soft 
parts,  sprains,  etc. 

It  may  be  applied  either  dry  or  moisi.  The  use  of  moist  cold  is  apt 
to  macerate  the  skin;  but  for  short  periods  of  time  moist  cold  is  very 
useful,  as  well  in  open  wounds  as  in  the  case  of  subcutaneous  injuries. 
In  crushes  of  the  extremities  it  is  often  possible  to  prevent  wide- 
spread sloughing  by  the  use  of  irrigation.  If  more  elaborate  appli- 
ances are  not  at  hand,  a  pitcher  may  be  hung  over  the  affected  part 
and  a  strip  of  gauze  arranged  to  act  by  syphonage  (Fig.  120).  Dry 
cold  is  most  conveniently  applied  by  means  of  the  ice  bag;  in  using 
this,  care  should  be  taken  to  see  that  a  fold  of  dry  lint  or  a  dry  towel 
is  kept  between  the  skin  and  the  ice  bag,  as  the  condensation  on  the 
surface  of  the  latter  will  soon  render  the  skin  wet,  and  may  cause 
superficial  sloughing.  Or  Petitgand's  method  of  mediate  irrigation 
may  be  employed:  a  coil  of  thin-walled  rubber  tubing,  of  convenient 
length,  is  wrapped  around  the  limb,  or  applied  to  the  head,  the  breast, 
etc.,  and  is  held  in  place  l)y  a  few  turns  of  a  roller  bandage;  a  stream 
of  cold  water  is  then  allowed  to  trickle  constantly  through  the  tube, 
being  collected  beside  the  bed  in  a  suitable  receptacle.  The  tempera- 
ture to  which  the  surface  of  the  inflamed  part  has  been  reduced  may  be 
ascertained  by  testing  the  fluid  as  it  runs  off".  Leiter's  coils,  which 
may  be  purchased  ready  made,  are  of  flexible  metal. 

Heat,  like  cold,  constringes  the  vessels  of  an  inflamed  part,  and 
though  not  actually  anesthesic,  may  prove  more  grateful  to  the  patient. 
In  the  form  of  a  hot  water  bag,  dry  heat  is  a  household  remedy. 
Baking  is  a  valuable  remedy  in  chronic  inflammation.  ]Moist  heat  is 
more  often  employed  in  acute  inflammation  than  is  dry.  It  is  useful  in 
sprains,  etc.,  as  an  earlj'  application  (hot  water  bath),  having  a  tend- 
ency to  limit  or  to  prevent  the  development  of  subcutaneous  edema. 
It  is  much  more  stimulating  than  cold,  and  when  the  circulation  is 
sluggish,  and  sloughing  is  threatened,  the  surgeon  may  sometimes 
a^'ert  the  danger  by  the  use  of  very  hot  compresses  frequently  renewed. 
The  use  of  moist  heat  in  the  form  of  a  poultice  is  very  agreeable  to 
the  patient,  and  is  one  of  the  most  efficient  ways  of  promoting  sup- 
puration when  this  is  inevitable,  as  well  as  in  hastening  the  separation 
of  sloughs  when  these  have  once  formed.  The  poultice  may  be  made 
aseptic  by  sterilizing  its  ingredients,  or  antiseptic  by  incorporating 
antiseptic  substances  in  it  when  it  is  being  made.  A  poultice  to  be 
useful  should  be  well  made;  and  unless  the  surgeon  knows  himself 
how  to  make  it  well,  he  cannot  expect  nurses  or  other  attendants 
to  be  particularly  careful  in  its  preparation.  Linseed  and  slippery 
elm  bark  are  the  usual  substances  employed.  For  the  separation  of 
sloughs  the  yeast,  or  fermenting  poultice  is  useful.  The  addition  of 
powdered  charcoal  will  make  the  poultice  efficacious  in  absorbing 
malodorous  gases.     The  method  of  preparing  poultices  is  described 


LOCAL   UEMEDIAL   TREATMENT  39 

in  Chapter  V.  All  poultices  should  he  covered  with  wtixed  paper  or 
other  iuipernieahlc  material,  so  as  to  retain  their  heat  and  moisture.  In 
the  treatment  of  badly  infected  wounds,  cellulitis,  etc.,  I  have  derived 
«>;reat  benefit  from  \\<\\\^  an  antiseptic  j)<)ultice  composed  of  gauze 
soaked  in  ecjual  parts  of  ('»()  i)er  cent,  alcohol  and  corrosive  sublimate 
solution  (i  to  2()(K)),  applied  dripi)in<f  wet,  and  thoroughly  covered  by 
waxed  paper  and  absorbent  cotton;  the  whole  dressing  is  then  held  in 
place  by  a  roller  l)andage.  It  is  sometimes  said  that  there  is  no  need 
to  use  antiseptics  in  wounds  which  already  are  infected,  and  that 
further  infection  will  do  good  by  establishing  a  free  discharge  of  pus. 
This  is  an  error;  if  there  is  no  discharge  of  laudable  pus  in  infected 
wounds,  it  only  shows  that  the  inflammation  is  extending,  and  that 
the  body  tissues  have  not  been  able  to  produce  a  sufficient  immber 
of  ])hagocytes  to  combat  and  to  vanquish  the  invaders.  Adding  to 
the  infection,  or  producing  a  mixed  infection,  will  not  mend  matters; 
it  should  rather  be  the  surgeon's  care  to  support  his  patient's  strength, 
and  to  aid  his  tissues  in  the  unequal  struggle  by  destroying  as  many 
as  possible  of  the  microorganisms  already  present. 

The  alternation  of  heat  and  cold,  in  the  form  of  douches,  is  useful  in 
the  later  stages  of  the  inflammatory  process,  aiding  in  the  absorption 
of  exudates  and  the  restoration  of  the  part  to  the  normal  condition. 

Narcotics  sometimes  are  applied  locally  with  benefit.  The  tincture 
of  arnica,  lead  water  with  laudanum  or  alcohol,  and  lately*  magnesium 
sulphate,  have  been  popular  at  various  times.  The  last  named  sub- 
stance has  the  effect  of  a  local  anesthetic,  and  very  remarkable  effects 
are  claimed  from  its  use  in  erysipelas  (Tucker,  1908),  arthritis,  orchitis, 
and  other  affections.  Belladonna  plaster  is  a  favorite  domestic  remedy. 
Ichthyol,  in  the  form  of  an  ointment  of  10  to  25  per  cent,  strength, 
is  useful  in  soothing  the  pain  of  adenitis,  in  furuncles,  etc.,  and  by  its 
sorbefacient  effect  seems  to  exert  a  directly  beneficial  influence  on  the 
course  of  inflammation.  Ointments  of  belladonna  and  mercury  are 
used  in  the  same  way.  The  internal  use  of  mercury  and  the  iodides 
may  be  combined  advantageously  with  these  local  applications. 

Counter-irritants,  when  applied  around  but  not  directly  over  the 
inflamed  part,  are  often  productive  of  considerable  benefit,  especially 
in  subacute  and  chronic  inflammations,  though  their  exact  mode  of 
action  is  still  a  matter  of  dispute.  Under  this  heading  come  blisters, 
iodin,  turpentine  stupes,  capsicum  and  mustard  plasters;  also  silver 
nitrate,  which  is  astringent,  and  copper  sulphate.  The  actual  cautery 
is   occasionally   of   value   as   a   counter-irritant. 

Local  bleediyig,  by  the  use  of  incisions,  or  by  means  of  leeches,  may 
be  of  value  in  combating  excessive  inflammatory  reaction.  It  will 
relieve  the  congestion,  may  perhaps  prevent  the  formation  of  a  harm- 
ful exudate,  and  almost  without  exception  diminishes  the  pain. 
Leeches  are  seldom  employed  at  the  present  day  except  in  affections 
of  the  eye  and  ear.  Venesection,  or  general  bleeding,  is  now  rarely 
employed.  In  cerebral  compression  its  use  is  illogical,  since  the 
increased  arterial  tension  is  the  effect,  not  the  cause,  of  the  lesion 


40  INFLAMMATION 

within  the  cranium.  But  in  the  robust,  plethoric,  or  cyanosed,  with 
symptoms  of  present  or  threatening  toxemia,  in  the  presence  of 
inflammation  of  the  sthenic  type,  venesection  is  sometimes  of  value. 

'J'hc  use  of  incisions  has  already  been  referred  to  under  the  head 
of  bleeding;  by  relieving  tension  they  serve  to  lessen  the  pain,  and 
may  prevent  sloughing  by  promoting  discharge  from  the  over-filled 
vessels  of  the  inflamed  area,  thus  aiding  in  the  restoration  of  the 
circulation.  The  pain  of  orchitis  is  readily  relieved  by  puncture  of 
the  tunica  albuginea;  after  plastic  operations  (for  hypospadias,  etc.) 
multiple  small  incisions  may  prevent  sloughing  by  reducing  the 
edema;  in  extensive  cellulitis  the  use  of  free  incisions  may  prevent 
the  development  of  widespread  sloughing  or  gangrene  (as  in  extrava- 
sation of  urine).  Finally  the  evacuation  of  pus  is  one  of  the  main 
indications  for  incision. 

Operations  are  frequently  required  in  the  treatment  of  inflamma- 
tion. Drainage  must  be  established  in  suppurative  affections  in  all 
parts  of  the  body  (brain  abscess;  empyema;  peritonitis);  an  invo- 
lucrum  must  be  cut  away;  sequestra  must  be  remo^'e(l;  amputation 
and  excisions  must  be  performed,  before  the  ultimate  cure  of  the 
disease  can  be  effected. 

Compression,  applied  before  the  inflammatory  process  has  reached 
its  height,  may  prevent  excessive  reaction;  in  the  later  stages  it  will 
assist  in  promoting  absorption.  Swelling  of  a  sprained  ankle  may  be 
prevented  by  strapping ;  a  carbuncle  will  rapidly  decrease  in  size  when 
thoroughly  suported  at  its  periphery  by  adhesive  plaster  straps; 
strapping  a  leg  ulcer  is  almost  indispensable  at  times. 

Aciire  and  passive  congestion,  as  introduced  by  Bier  (1905),  act  in 
a  truly  remarkable  manner  in  some  inflammatory  aftections.  Con- 
gestion lessens  the  pain  by  benumbing  the  p&rt,  probably  by  direct 
pressure  on  the  nerve  endings  through  the  subcutaneous  edema  pro- 
duced, acting  thus  much  like  the  usual  forms  of  infiltration  anesthesia. 
It  produces  its  curative  effect  probal)ly  by  increasing  the  number  of 
phagocytes  in  the  part;  possibly  also  by  increasing  the  quantity  of 
the  exudate  and  thus  enhancing  its  bactericidal  properties.  It  has 
seemed  to  me  that  the  value  of  compression  in  carbuncles  and  chronic 
ulcers  may  be  due  at  least  in  some  measure  to  the  chroiiic  passive 
hyperemia  produced.  Passive  congestion  is  most  used  in  the  treatment 
of  chronic  arthritis;  it  is  also  of  value  in  such  localized  infections  as 
furuncles,  felons,  etc.;  it  is  usually  useless  or  actually  harmful  in 
spreading  inflammations.  Passive  congestion  is  to  be  secured  by 
bandaging  the  liml)  some  distance  above  the  lesion  with  an  elastic 
bandage  which  is  drawn  tight  enough  to  obstruct  the  venous  current 
without  intercepting  the  arterial.  The  limb  below  the  seat  of  the  con- 
striction should  develop  a  comforting  glow,  the  superficial  venules 
being  distended,  and  the  skin  becoming  a  dusky  blue.  Under  no  cir- 
cumstances should  the  constriction  be  tight  enough  to  cause  a  fall  of 
temperature  in  the  limb.  At  first  the  treatment  is  continued  for  only 
one  hour  dailv,  but  later  mav  be  used  almost  continuously.     Active 


CONSriTJTlOSAL    TRKATMEST  41 

hyperemia  is  securctl  hy  liot  air  apijlicatioiis  (hakiiiji  (ir  tlic  hot  air 
tloiK-he),  or  l)y  the  list-  of  ciipj)in^f  ^Masse>,  which  are  made  in  torm> 
suitable  to  the  various  parts  arteeted.  leaking  is  partieuhiriy  appHcahie 
to  chrouie  forms  of  artliritis  witliout  efi'usion;  wliile  the  eupi)in^  glass 
apparatus  is  said  to  he  of  value  in  tlie  treatment  of  chronic  sinuses, 
ete. ;  it  has  also  been  used  in  uterine  attections.  It  is  probable  that  the 
novelt\'  of  this  treatment  is  causing  it  to  be  indiscriminately  employed 
in  many  atieetions  where  it  can  only  do  harm. 

Massage  is  of  value  in  the  later  stages  of  inflammation,  by  pro- 
moting absorption  of  the  exudate,  rupturing  slight  inflammatory  adhe- 
sions; and  thus  aiding  the  restoration  of  normal  i:)hysiological  action. 
In  enforced  confinement  to  bed,  massage  may  be  advisable  to  sustain 
the  tone  of  the  muscles  of  those  parts  not  directly  concerned  in  the 
disease. 

Constitutional  Treatment. — ConstituiionaJ  rest,  as  well  as  local  rest 
of  the  inflamed  })art,  is  often  requisite.  Rest  in  bed,  in  a  quiet,  cool, 
darkened  room,  may  enable  the  patient  to  be  restored  to  his  activi- 
ties in  a  few  days,  whereas  a  much  longer  period  frequently  would  be 
required  were  he  to  persist  in  going  about  the  house.  Especially 
should  such  rest  be  insisted  upon  in  the  case  of  acute  inflammations 
of  the  chief  organs  of  the  body — pyelitis,  cystitis,  prostatitis,  affec- 
tions of  the  gall-bladder  and  other  abdominal  organs. 

Hy(/iene  is  of  the  utmost  importance.  The  room  of  the  patient, 
or  the  hospital  ward,  should  be  well  ventilated,  and  easily  warmed 
in  winter,  and  cool  in  summer.  Bathing  must  not  be  neglected,  for 
the  skin  is  an  important  excretory  organ.  The  excretions  must  be 
watched  daily,  and  in  most  cases  a  careful  examination  of  the  urine 
should  be  made,  both  as  to  quality  and  quantity.  Cathartics  should 
be  given  as  needed;  a  brisk  purge  early  in  the  attack  is  usually  bene- 
ficial. A  temperature  chart  should  be  kept,  and  the  temperature, 
pulse,  and  respiration  be  recorded  twice  daily.  As  the  patient  will 
often  be  unable  to  entertain  himself  while  laid  up,  the  surgeon  should 
see  that  such  light  entertainment  as  is  deemed  suitable  is  provided. 
The  best  surgeons  are  physicians  also,  and  must  not  let  their  pro- 
fessional duty  cease  with  the  dressing  of  the  wound  or  the  applica- 
tion of  a  splint.  On  the  other  hand,  I  have  sometimes  seen  patients 
who  were  exhausted  by  over-entertainment,  all  the  members  of  the 
family  congregating  in  the  sick  man's  room  to  spend  the  evening, 
vitiating  the  atmosphere,  and  wearying  the  patient's  mind  by  constant 
chattering  among  themselves.  It  is  usually  well  to  limit  the  visitors 
to  two  at  a  time;  and  to  caution  them  to  cease  their  visit  and  their 
conversation  when  the  sick  man  no  longer  appears  interested. 

The  diet  in  cases  of  inflammation  should  be  simple;  so  long  as  fever 
continues,  liquid  diet  is  preferable.  ^Milk,  which  is  the  most  univer- 
sally applicable  article  of  food,  usually  can  be  taken  by  any  patient, 
in  spite  of  his  prejudices,  if  he  makes  the  attempt,  ajid  if  the  milk  is 
fresh  and  cold.  A  few  patients  prefer  it  warmed.  Its  taste  may  be 
disguised  by  the  use  of  vanilla,  chocolate,  coffee,  etc.     All  kinds  of 


42  INFLAMMATION 

broths  are  suitable;  fresh  beef  jiiiee  often  is  rehshed,  or  the  various 
prepared  forms  of  meat  juice  may  l)e  employed.  Liquid  peptonoids 
is  an  excellent  article  of  diet.  When  the  fever  has  gone,  more  liberal 
diet  may  be  allowed :  eggs,  oysters,  sweetbreads,  chicken,  chops,  green 
vegetables,  ice-cream,  etc.  As  a  rule,  the  patient's  own  desires  and 
tastes  furnish  a  fairly  reliable  guide  to  his  diet;  and  if  no  injurious 
effects  are  manifest,  he  may  be  permitted  to  eat  pretty  much  what  he 
pleases. 

Drugs  are  of  undoubted  value  in  the  treatment  of  inflammation. 
Those  most  employed  may  be  classed  as  (1)  Sedatives;  (2)  Cathartics; 
(3)  Diuretics  and  Diaphoretics;  (4)  Stimulants;  (5)  Alteratives;  (6) 
Tonics. 

Sedatives.- — Opium  is  one  of  the  most  valuable  single  remedies  in 
the  pharmacopoeia;  but  its  tendency  to  produce  constipation  must 
be  guarded  against;  and  it  is  too  valuable  a  remedy  to  be  used  indis- 
criminately. I  never  prescribe  it  unless  there  appears  to  be  a  definite 
therapeutic  indication  for  its  use;  I  consider  its  routine  use  in  opera- 
tions or  other  surgical  affections  as  extremely  injudicious.  If  the 
patient  is  in  pain,  it  is  the  surgeon's  duty  to  relieve  the  pain  so  far  as 
is  compatible  with  the  cure  of  the  disease;  but  usually  pain  may  be 
relieved  without  resort  to  opium,  by  change  of  position,  by  prompt 
incision  of  an  abscess,  or  by  rest  enforced  by  splint  or  bandages.  If 
the  pain  really  demands  morphin  for  its  relief,  I  think  it  is  usually 
better  to  administer  one-sixth  of  a  grain  hypodermically,  and  to 
repeat  this  in  an  hour  if  the  patient  is  not  relieved.  In  extensive 
burns,  I  order  a  quarter  of  a  grain  for  an  adult  immediately,  and  have 
this  dose  repeated  at  short  intervals  until  relief  is  obtained.  There  is 
no  torture  so  great  as  that  of  a  burn  so  extensive  as  to  ensure  death 
within  a  few  hours;  and  it  is  inhuman  to  withhold  the  means  of  euthan- 
asia from  such  patients.  Closely  allied  to  its  power  of  producing  sleep, 
is  the  action  of  opium  for  injuries  of  the  head,  in  traumatic  delirium, 
delirium  tremens,  etc.  Besides  relieving  pain  and  securing  sleep, 
opium  serves  to  relax  spasm;  it  thus  proves  of  benefit  in  fractures; 
in  retention  of  urine  from  congestion  of  the  posterior  urethra,  in  fissure 
of  the  anus,  in  pylorospasm,  and  similar  aft'ections. 

If  opium  is  contraindicated,  other  sedatives  may  take  its  place; 
among  the  most  valuable  of  these  are  chloral,  the  bromides,  hyoscin, 
cannabis  indica,  and  paraldehyde.  Trional  is  a  useful  hypnotic,  but 
has  no  influence  on  pain.  Aconite  may  be  given  in  small  doses  during 
the  height  of  the  inflammatory  fever,  when  of  the  sthenic  type. 
Veratrum  viride  and  antimony  are  now  seldom  used.  The  latter  was 
formerly  employed  in  the  endeavor  to  abort  inflammation  by  means 
of  its  so-called  "anticipatory  antiplastic  eftect."  Calomel,  for  the 
same  purpose,  was  strongly  commended  by  the  late  Prof.  Ashhurst, 
in  the  treatment  of  head  injuries,  and  I  constantly  employ  it  with 
utmost  satisfaction. 

Catharatics  usually  may  be  administered  with  benefit  in  the  early 
stages  of  inflammation.  In  this  way  toxins  are  withdrawn  from  the 
circulating  blood,  and  prevented  from  reaching  the  kidneys  in  excess, 


CONSTirVTIONAL   TREATMENT  43 

u  here  they  ;ire  prone  to  ciiuse  (•h)U(ly  swelhii'''  or  (les(|ii;iiiiat  i\ c  neph- 
ritis. In  ])eritonitis  1  heHe\e  the  use  ol'  eathiirties  to  he  positively 
harinfiil.  In  inenin<;itis  it  is  desirahle  to  keep  the  bowels  freely  oj)en. 
A  single  dose  of  castor  oil,  or  blue  i)ill,  or  divided  doses  of  calomel 
(gr.  g  hourly  till  gr.  j  has  been  taken)  will  be  of  more  benefit  in  most 
cases  than  the  popular  use  of  salts.  After  having  the  bowels  thoroughly 
o])ened  once,  it  is  usually  inadvisahle  to  continue  purging  the  patient. 
If  constii)ation  i)ersists,  enemas  may  be  used.  AsafVx'tida  supposi- 
tories, or  milk  of  asafoetida  by  enema,  are  supposed  to  overcome 
flatulence.  1  have  considerable  doubt  whether  they  have  any  very 
definite  action. 

Diurciics  and  diaphoretics  were  much  employed  formerly,  and 
they  undoubtedly  are  of  benefit  in  some  cases.  Plenty  of  water  by 
mouth  is  the  best  diuretic;  when  this  is  contraindicated,  or  if  it  can- 
not be  taken,  resort  may  be  had  to  rectal,  subcutaneous,  or  intraven- 
ous injections  of  saline  solution.  The  kidneys  are  the  chief  organs  of 
elimination  for  the  toxins  produced  at  the  seat  of  inflammation,  and 
by  the  iml)ibition  of  plenty  of  fluid  the  function  of  the  kidneys  is 
promoted,  and  the  toxins  are  excreted  in  a  more  or  less  diluted  form. 

Dover's  powder  combines  the  merits  of  an  hypnotic  with  those 
of  a  diaphoretic.  The  vegetable  salts  of  potassium  and  ammonium 
(citrate  and  acetate)  are  especially  valuable  as  diuretics  because  they 
are  not  themselves  irritating;  moreover,  they  lessen  the  viscosity  of 
the  blood.  Digitalis  and  strophanthus  are  more  stimulating;  these, 
or  the  citrate  of  caff'ein,  may  be  used  when  the  heart  shows  signs  of 
failure. 

Stivwiants  seldom  can  be  dispensed  with  in  severe  cases  after  the 
height  of  the  fever  has  passed.  Alcohol,  when  taken  in  small  quanti- 
ties, aids  the  al)sorption  of  food;  it  seems  to  act  almost  as  a  food  itself 
when  little  else  can  be  retained.  It  should  be  given  in  doses  large 
enough  to  produce  the  desired  effect;  the  amount  naturally  will  vary 
with  the  age  and  habits  of  the  patient,  with  his  general  condition, 
and  with  the  condition  of  his  heart  and  kidneys.  The  initial  dose 
should  be  small  (one-half  ounce  three  or  four  times  daily),  and  it 
should  be  increased  rapidly  so  long  as  it  appears  to  do  good.  In  men- 
ingitis it  is  contraindicated,  as  tending  to  increase  delirium;  but  in 
delirious  states  due  purely  to  adynamia,  as  in  extensive  burns,  or 
other  exhausting  diseases,  the  use  of  tonic  doses  of  alcohol  frequently 
will  cause  the  mental  state  to  clear  up  promptly.  Its  use  in  delirium 
tremens  is  to  be  condemned.  If  the  delirium,  from  any  cause,  is 
increased  by  the  alcohol,  it  is  doing  the  patient  no  good,  and  should 
be  reduced  in  quantity  or  discontinued  entirely.  Whisky  and  brandy 
are  the  })est  forms  in  which  to  administer  alcohol  during  the  inflam- 
mation; during  convalescence,  ale,  beer,  porter,  or  the  lighter  wines 
may  be  used.  Champagne  is  the  only  form  in  which  it  is  usually 
advisable  to  administer  alcohol  during  the  continuance  of  high  fever. 

Coffee  is  a  valuable  stimulant.  It  may  be  administered  by  mouth 
or  bv  enema.    The  same  is  true  of  salt  solution,  as  alreadv  noted  when 


44  INFLAMMATION 

speakinjj;  of  diuretics.  Atropiu,  (li<i;italis,  and  camphor  are  ^ooi\ 
cardiac  and  vascular  stimulants.  I  do  not  think  much  of  strychnin 
except  as  a  tonic. 

Alteratives  are  used  frequently  in  inflammation.  The  em{)loyment 
of  mercury  to  cause  the  absorption  of  inflammatory  exudates  (iritis, 
meningitis,  etc.)  is  world-wide.  Calomel  is  usually  the  best  form  for 
administration.  The  iodides  of  potassium,  sodium,  etc.,  are  widely 
used  to  aid  in  the  elimination  of  inflammatory  products,  especially 
in  affections  of  the  bones  and  joints. 

Tonics.— Dwvmg  convalescence  it  is  almost  always  proper  for  the 
patient  to  take  a  tonic.  Iron  and  quinin  are  the  most  valuable. 
Some  patients  will  prefer  Blaud's  pills  to  the  tincture  of  the  chloride 
of  iron,  but  the  latter  frequently  is  more  eft'ective.  The  tincture  of 
nux  vomica,  or  strychnin  sulphate,  with  one  of  the  bitters,  aids 
materially  in  the  restoration  of  appetite.  In  the  case  of  children, 
cod  liver  oil,  the  phosphates,  or  arsenic  may  be  given. 

Stimulation  of  Phagocytosis. — This  method  has  been  attempted  in 
both  the  prevention  and  treatment  of  inflammation.  Mikulicz  used 
local  hypodermic  injections  of  dilute  nucleinic  acid,  in  the  effort  to 
increase  by  positive  chemotaxis  the  number  of  phagocytes  and  their 
bactericidal  power  for  the  prevention  of  peritonitis.  Local  inunctions 
of  mercury  are  said  to  act  in  a  similar  way.  The  use  of  Bier's  passive 
hyperemia  has  already  been  referred  to. 

Vaccines  and  Serum  Therapy  in  General;  the  Opsonic  Theory. — The 
phenomena  of  the  inflammatory  process  are  merely  exaggerations 
of  phenomena  which  are  constantly  occurring  in  the  body  in  a  state 
of  health.  As  already  mentioned,  it  is  extremely  probable  that 
bacteria  of  some  kind  are  constantly  present  in  the  body,  and  that 
phenomena  of  disease  are  prevented  only  by  the  natural  resistance 
of  the  body  tissues.  Opsonins,  as  pointed  out  at  p.  23,  are  normally 
present  in  the  fluids  of  the  circulating  blood.  When  local  inflamma- 
tion or  general  disease  arises,  these  resistive  powers  of  the  organism 
are  increased;  various  other  antibodies  are  produced,  and  on  recovery 
from  a  certain  disease  a  condition  of  immunity  to  that  special  infec- 
tion may  be  established,  and  may  continue  for  a  longer  or  a  shorter 
time.  This  immunity  may  be  conceived  of  as  being  due  to  the  cells 
of  the  body  having  acquired  by  training  the  habit  of  resisting  a  certain 
specific  infection;  so  that  should  this  same  infection  again  occur,  the 
body  cells  would  be  fully  prepared,  as  the  result  of  their  previous 
experience,  to  act  rapidly  and  eftectively  in  repelling  the  foe.  Their 
habit  of  forming  antibodies  will  result  in  attempts  at  re-infection 
proving  ineft'ectual. 

The  earliest  instance  in  which  practical  application  was  made  of 
the  above  theory,  though  of  course  the  principle  itself  was  not  then 
understood,  was  the  use  of  vaccination  by  Jenner  (1798);  in  the  origi- 
nal method  the  virus  of  the  cowpox  was  inoculated  into  man,  thus 
producing  in  him  the  disease  known  as  vaccinia,  which  was  considered 
to  be  a  mild  form  of  smallpox,  the  virulence  of  the  smallpox  virus 


VACCINES  AM)  SKRVM   TIIEHAI'Y  IN  GENERAL  45 

having  beeiv attenuated  by  passing  through  tlie  cow.  \\\  thus  training 
the  body  cells  to  reaction  against  the  ^■irus  of  cowijox,  an  iiinnunity 
to  smallpox  is  estal)lished. 

The  term  vaccines  is  apj)lied  to  those  substances,  used  for  pro- 
phylactic or  curative  injection,  which  contain  the  attenuated  virus 
itself,  not  merely  some  of  the  anti-bodies  profluced  in  the  course  of 
the  disease.  Most  vaccines  contain  no  bacteria  which  have  not  been 
killed.  Those  substances  whic-h  contain  anti-bodies  an'l  i)erhaps 
dead  bacteria,  but  certainly  no  living  virus,  are  classed  as  sera;  they  are 
subdixided  into  aniitoxic  and  antibacterial  sera.  By  the  use  of  the 
opsonic  index,  the  use  of  vaecines  and  sera  may  be  judiciously  con- 
trolled. By  collecting  in  a  capillary  pipette  equal  amounts  of  (1)  the 
])atient's  blood  serum,  (2)  blood  corpuscles  washed  in  a  solution  of 
one-half  per  cent,  sodium  citrate  in  normal  salt  solution,  and  (3) 
an  emulsion  of  the  specific  bacteria  of  the  disease  from  which  the 
patient  suffers;  and  by  then  examining  properly  pre])ared  slides 
spread  with  the  above  fluid,  the  average  number  of  bacteria  ingested 
by  each  polynuclear  leukocyte  is  determined.  By  comparing  this 
average  number  with  the  average  number  of  similar  bacteria  ingested 
by  the  leukocytes  in  a  fluid  similarly  prepared  from  the  serum  of  a 
normal  indixidual,  we  obtain  a  ratio  which  may  be  expressed  as  an 
index  by  reducing  the  formula  to  unity.  Thus  if  the  average  number 
of  bacteria  ingested  in  the  first  examination  (the  patient)  was  2,  and 
that  in  the  second  examination  (normal  individual)  was  4,  we  obtain 
a  ratio  of  2  to  4,  or  of  0.5  to  1.0.  We  then  speak  of  1.0  as  the  normal 
opsonic  index,  and  record  the  opsonic  index  of  the  patient  as  0.5 
(Primrose,  1907).  By  means  of  this  opsonic  index  it  is  possible,  in 
a  way  which  so  far  is  still  rather  empirical,  to  administer  vaccines 
and  sera  so  as  to  increase  tlie  patient's  opsonic  index,  and  thus 
promote  the  cure  of  the  disease.  This  method  has  been  employed 
chiefly  in  the  treatment  of  tuberculosis. 

Prophylaxis  and  treatment  by  vaccines  and  sera  are  most  suc- 
cessful in  the  case  of  diseases  caused  by  specific  microorganisms. 
Ordinary  inflammations,  in  which  the  cause  is  not  a  specific  micro- 
organism, have  not  so  far  been  treated  with  very  encouraging  results. 
Among  diseases  treated  by  vaccines  may  be  mentioned,  besides  the 
prevention  of  smallpox  already  referred  to,  the  prophylaxis  and  cure 
of  anthrax  (Pasteur),  rabies  (Pasteur),  typhoid  fever  (Frankel, 
Richardson),  and  tuberculosis  (Koch,  AVright).  Among  those  treated 
by  sera  are  included:  (1)  By  antitoxic  sera,  diphtheria  (Behring), 
tetanus  (Behring) ;  (2)  By  antibacterial  sera,  typhoid,  cholera,  plague, 
dysentery,  etc.  Finally  by  the  administration  of  both  vaccines  (active 
immunization)  and  sera  (passive  immunization),  encouraging  results 
have  been  obtained  in  anthrax  by  vSclavo  (1903). 

Antistreptococcic  serum  has  been  extensively  used  on  general 
principles  in  ordinary  types  of  spreading  inflammation,  in  erysipelas, 
and  in  septicemia.  (See  Chapter  II.)  It  is  an  antibacterial  serum. 
The  results  are  sometives  mar\ellous,  while  more  often  its  use  appears 


4ri  IN  FLA  MM  A  TION 

to  be  devoid  of  effect  of  any  kind.  Anticolon  bacillus  serum  has  also 
been  used  by  some  observers,  but  without  very  constant  results. 
As  a  general  statement,  it  may  be  said  that  in  acute  diseases,  where 
it  is  necessary  to  supply  the  patient  with  anti-bodies  already  formed, 
sera  are  used;  while  in  chronic  infections,  it  is  hoped  by  the  adminis- 
tration of  killed  bacteria  to  rouse  the  patient's  tissues  to  a  more 
effectual  production  of  anti-bodies. 


CHAPTER   II. 

DISEASES  RESULTING  FROM  INFLAMMATION. 

The  .siirfi;ical  diseases  resulting  from  inflamiiiatioii  may  be  elassified 
as  (1)  Local  Affections,  incliuling  Abscess,  Ulcer,  Gangrene,  Cellulitis, 
Erysipelas,  etc.;  and  (2)  General  Affections,  iucludino;  under  the  gen- 
eral name  of  Sepsis,  the  varieties  of  systemic  infection  known  as 
Sapremia,  Toxemia,  Bacteriemia  (Septicemia),  and  Pyemia. 

LOCAL  AFFECTIONS. 

Abscess. — The  pathogenesis  of  an  abscess  has  been  described 
already  (p.  25),  and  it  may  be  defined  as  a  collection  of  pus  circum- 
scribed by  granulation  tissue.  If  the  pus  is  not  circumscribed  by 
granulation  tissue,  it  is  not  spoken  of  as  an  abscess.  Thus  pus  in  the 
pleural  cavity  is  an  empyema,  if  widely  diffused;  it  does  not  become 
an  abscess  until  it  is  walled  off  from  the  general  cavity  by  the  effusion 
of  lymph  and  the  production  of  adhesions.  Pus  widely  infiltrating 
the  cellular  or  muscular  tissues  does  not  form  an  abscess,  but  a 
phlegmon.  Pus  free  in  the  peritoneal  cavity  is  described  not  as  an 
abscess  of  the  peritoneum,  but  as  diffuse  suppurative  peritonitis. 

Two  main  varieties  of  abscess  are  recognized;  these  are  distinguished 
clinically  by  their  symptoms,  but  the  pathogenesis  of  both  is  the 
same;  they  are  the  acute  or  phlegmonous  abscess,  and  the  chronic, 
cold,  or  scrofulous  abscess.  The  former  alone  is  to  be  considered 
here ;  cold  abscess  is  described  in  connection  with  surgical  tuberculosis, 
in  Chapter  III. 

Clinical  Pathology. — An  abscess  may  arise  in  any  place  where 
inflammation  exists.  It  may  be  caused  by  direct  injury  of  the  part, 
as  by  a  fall,  a  kick,  an  infected  wound,  etc.;  or  it  may  arise  second- 
arily, as  the  result  of  extension  of  inflammation  from  the  primary 
focus.  This  extension  may  occur  along  the  subcutaneous  (sub- 
peritoneal, etc.)  areolar  tissue  (causing  cellulitis),  along  the  lymphatic 
channels  (causing  lymphangeitis),  or  along  the  blood  stream  (causing 
phlebitis,  and  very  rarely  arteritis).  When  an  abscess  is  suspected 
in  a  region  which  has  not  been  directly  injured,  careful  search  should 
therefore  be  made  for  the  original  focus  of  infection;  and  it  should 
not  be  forgotten  that  the  intervening  tissues  may  show  no  evidence 
of  disease.  Thus  a  sore  on  the  foot  may  cause  inflammation  and 
eventual  suppuration  in  the  femoral  or  inguinal  lymph  nodes,  without 
any  evidences  of  lymphangeitis  of  the  leg  or  thigh.  Abscess  of  the 
liver  may  follow  appendicitis,  the  virus  of  the  disease  ha\'ing  traversed 


48 


DISEASES  RESULTING  FROM  INFLAMMATION 


the  radicles  of  the  portal  vein  without  leaving  evidences  of  its  passage. 
Infection  from  a  wound  of  the  mouth  may  spread  to  the  areolar 
tissue  of  the  neck,  and  there  cause  cellulitis  and  suppuration  without 
giving  signs  of  inflamraation  in  the  tissues  of  the  floor  of  the  mouth 
through  which  it  passed.  But  in  each  and  every  case,  before  suppura- 
tion can  occur,  the  earlier  stages  of  inflammation  must  have  existed 
in  the  part  in  which  the  abscess  is  ultimately  formed. 

As  the  pus  within  the  abscess  accumulates,  by  progressive  lique- 
faction necrosis  of  the  surrounding  layer  of  lymph,  the  size  of  the 
abscess  increases;  it  spreads  most  rapidly  in  the  direction  of  least 
resistance  (usually  toward  the  skin  surface),  and  pointinrj  of  the 
abscess  is  said  to  occur  when  the  pus  is  contained  by  the  epidermis 
alone.  Occasionally  an  abscess  will  point  and  rupture  into  a 
neighboring  cavity,  as  a  joint,  or  one  of  the  great  serous  cavities 
(pleura,  pericardium,  etc.) ;  but  in  the  case  of  suppuration  in  internal 
organs,  sufficient  plastic  lymph  at  times  is  produced  to  confine  the 
abscess  on  its  inner  surface,  and  to  pre\'eut  rupture  except  externally. 
When  an  abscess  is  evacuated,  the  tract  through  which  it  discharges 
is  called  a  sinus  (p.  52).  A  fistula  is  a  sinus  which  has  two  or  more 
openings ;  these  may  be  on  the  skin,  or  one  may  be  on  the  skin,  another 
in  an  internal  cavity  (intestine,  joint,  urethra,  etc.),  or  both  may  be 
internal  openings  (as  in  gastro-colic,  recto-vesical,  and  other  similar 
fistuhe) . 


Fig.  6. — Abscess  of  the  groin,  following  direct  injury,  one  month  previously. 
Girl,  aged  eleven  years.     Episcopal  Hospital. 


Symptoms. — At  the  onset  of  suppuration,  the  part  alreadN'  inflamed 
becomes  more  painful,  the  pain  assuming  a  throbbing  or  pulsatile 
character;  the  tenderness  is  accentuated;  the  intense  redness  of  the 
inflammation  fades  into  a  dusky  or  a  bluish  hue;  the  swelling 
becomes  better  localized;  and  frequently  the  abscess  is  seen  to 
stand  out  above  the  surface  of  the  surrounding  skin  (Fig.  6).  As 
the  amount  of  fluid  within  the  abscess  cavity  increases,  fluctuation, 


ABSCESS 


49 


at  first  indistinct,  becomes  unmistakable;  the  skin  over  the  abscess 
may  (les(|uamate;  it  becomes  thinner  and  thinner,  and  finally  is 
entirely  deprived  of  its  nutrition  at  the  point  of  greatest  tension. 
A  minute  circular  slough  is  then  formed  at  this  point,  and,  when 
this  is  cast  ofi",  the  pus  from  within  is  discharged,  the  abscess 
cavity  is  more  or  less  obliterated  by  the  pressure  of  surrounding 
parts,  and  the  abscess  is  finally  converted  into  a  granulating 
surface.  When  suppuration  is  deeply  seated,  an  abscess  may 
attain  a  considerable  size  before  producing  such  characteristic  symp- 
toms. In  such  cases  the  overlying  skin  may  become  edematous, 
pitting  slightly  on  pressure,  owing  to  the  eft'usion  of  lymph  and 
serum  in  the  overlying  parts;  rigidity  and  immobility  of  the  pro- 
tecting muscles  are  important  signs;  and  the  experienced  touch  of 
the  surgeon  may  enable  him  to  proclaim  with  certainty  the  presence 
of  pus,  when  to  one  not  possessed  of  the  tacius  eruditus  a  positive 
diagnosis  would  be  impossible. 


Fig.  7. — Instruments  used  in  treatment  of  abscess:    bistoury,  eyed  probe, 
dressing  forceps,  exploring  needle. 


Diagnosis. — It  is  not  likely  that  an  acute,  superficial  abscess, 
already  pointing,  will  be  mistaken  for  anything  else.  But  there 
are  many  other  affections  with  which  an  abscess  at  times  may  be 
confused.  Careful  and  systematic  examination  of  the  patient  should 
therefore  never  be  neglected.  The  brilliant  Irish  surgeon,  Dease, 
recklessly  plunged  his  bistoury  into  a  swelling  in  the  femoral  region, 
which  he  mistook  at  first  glance  for  an  abscess,  and  his  patient  died 
before  his  eyes  from  overwhelming  and  uncontrollable  hemorrhage 
from  the  femoral  artery,  an  aneurysm  of  which  vessel  had  been  opened. 
The  diagnosis  of  an  acute  abscess  ma}-  be  determined  by  the  history, 
by  the  local  sigm  (fluctuation,  pointing,  etc.),  and  as  a  last  resort 
by  the  exploring  needle  (Fig.  7).  Fluctuation  may  be  present  more 
or  less  distinctly  in  many  other  swellings  than  those  containing  pus; 
besides  aneurysms,  effusions  of  blood,  of  serum,  of  urine,  etc.,  may 
produce  such  fluctuating  swellings;  and  cystic  and  even  fatty  and 
some  other  solid  tumors  may  give  a  similar  sensation.  The  surgeon's 
fingers,  moreover,  in  palpating  a  suspicious  swelling,  should  be  placed 
longitudinally  on  the  part,  since  the  belly  of  a  large  muscle,  and 
4 


50  DISEASES  RESULTING  FROM  INFLAMMATION 

even  very  fatty  subcutaneous  tissues  may  present  indistinct  fluctuation 
if  this  point  be  neglected.  The  exploring  needle,  or  what  is  better 
if  at  hand,  an  ordinary  hypodermic  syringe,  may  be  used  to  ascertain 
the  presence  and  nature  of  the  fluid  in  a  doubtful  case. 

Prognosis. — This  is  good  in  most  cases,  provided  treatment  is 
prompt  and  efficient.  But  an  abscess  may  be  dangerous  from  its 
situation,  from  its  size,  or  the  prognosis  may  be  peculiarly  grave 
from  the  constitutional  condition  of  the  patient,  or  his  age.  A 
retropharyngeal  abscess  may  cause  suffocation;  one  in  close  proximity 
to  a  large  bloodvessel  may  rupture  into  it,  and  cause  death  from 
hemorrhage  or  from  pyemia;  an  abscess  near  a  joint  may  penetrate 
its  capsule  and  cause  lasting  disability  or  even  death  from  pyar- 
throsis;  an  abdominal  abscess  may  rupture  into  the  peritoneum  and 
cause  fatal  peritonitis.  The  drain  on  the  patient's  vitality  from  a 
large  abscess,  or  from  many  smaller  abscesses,  may  lead  to  death 
from  exhaustion,  or  from  amyloid  degeneration  of  the  viscera.  In 
practically  every  case  there  will  be  loss  of  tissue,  and  a  more  or  less 
evident  cicatrix  for  years  after  the  abscess  has  healed . 

Treatment. — ^Much  may  be  done  to  prevent  the  formation  of  an 
abscess,  as  pointed  out  in  discussing  the  treatment  of  inflammation. 
When  pus  has  once  formed,  much  may  be  done  to  ameliorate  the 
symptoms,  and  to  cure  the  patient  with  as  little  disfigurement  as 
possible.  Though  the  process  of  pointing  can  seldom  be  hastened, 
yet  by  appropriate  treatment  the  sufferings  of  the  patient  may  be 
very  materially  relieved  until  pointing  occurs.  Heat  or  cold,  which- 
ever proves  most  grateful,  may  be  applied  locally,  and  anodynes  may 
be  administered  internally,  when  required.  Warm  moist  heat,  in 
the  form  of  a  poultice,  usually  is  most  grateful  to  the  inflamed  part. 
But  though  these  adjuvants  may  be  employed  with  advantage  in 
certain  cases,  prompt  evacuation  of  the  pus  by  incision  is  much 
more  efficient  in  checking  pain,  by  relieving  tension  and  hastening 
the  conversion  of  the  abscess  into  a  superficial  ulcer.  Moreover, 
the  cicatrix  resulting  from  a  well-placed  incision  is  much  less  dis- 
figuring than  one  which  occurs  when  an  abscess  is  allowed  to  burst 
of  itself.  In  most  abscesses  affecting  the  subcutaneous  tissues  it  is 
better  to  postpone  incision  until  fluctuation  is  evident,  and  until 
pointing  has  nearly  occurred;  but  in  other  cases  incision  should  be 
adopted  much  earlier,  general  or  local  anesthesia  being  employed 
as  may  seem  indicated.  When  only  the  skin  intervenes  between  the 
abscess  and  the  surface  of  the  body,  no  anesthetic  is  required,  for 
freezing  the  skin  or  the  use  of  hypodermic  injections  of  cocain  is 
quite  as  painful  as  the  momentary  stab  of  a  bistoury;  moreover, 
the  skin  overlying  such  an  abscess  has  nearly  all  its  nerves  devitalized 
by  the  anemic  necrosis  induced  by  pressure  of  the  pus.  In  the  case 
of  deeper  abscesses,  I  much  prefer  tljc  hypodermic  use  of  cocain  to 
freezing  by  the  ethyl  chloride  spray;  and  when  the  cocain  is  properly 
used  the  entire  procedure  is  painless  except  for  the  initial  prick  of 
the  needle.     When  the  abscess  is  still  more  inaccessible,   general 


ABSCESS 


51 


anesthesia  is  to  be  preferred,  since  in  some  instances  it  may  be 
necessary  to  undertake  a  formal  operation,  or  even  to  oi)en  the  abscess 
across  a  serous  cavity  (puhnoiiary,  appendicular,  cerebral  abscess). 
In  opening  a  superficial  abscess  without  any  local  anesthesia,  the 
surgeon  should  accomplish  his  purpose  by  a  sudden  thrust  of  the 
bistoury,  which  is  held  as  a  pen,  and  with  its  cutting  edge  toward 
the  surgeon;  thus,  as  the  patient  draws  away  in  momentary  surprise 
or  pain,  the  .incision  will  be  enlarged  as  the  bistoury  is  witlidrawn. 
The  dei)th  to  which  it  is  to  be  introduced  must  be  determined  before- 
hand, and  regard  must  be  had  to  the  anatomy  of  the  part,  lest  some 
important  nerve  or  vessel  be  wounded.  In  opening  an  abscess  in  a 
dangerous  neighborhood  it  is  much  safer  to  adopt  Hilton's  method: 
to  incise  merely  through  the  skin  and  superficial  fascia,  and  then  to 
introduce  a  grooved  director,  and  burrow  down  to  the  abscess  with 
this,  or  with  a  dressing  forceps;  when  the  pus  is  reached,  the  blades 
of  the  forceps  are  widely  separated  and  the  forceps  is  withdrawn, 
thus  dilating  the  tract  previously  made. 

When  an  abscess  has  been  opened,  it  should  be  allowed  to  dis- 
charge itself  slowly;  the  surgeon  may  gently  support  its  sides,  to 
encourage  the  discharge  of  pus,  but  he  should  by  no  means  attempt 
to  express  it  by  massage,  and  most  em- 
phatically should  he  not  introduce  a 
curette  into  the  abscess  cavity  to  scrape 
away  its  lining  membrane.  Such  a  course 
destroys  the  granulation  tissue  surround- 
ing the  abscess  cavity,  may  open  neigh- 
boring venules  or  lymphatic  radicles, 
and  is  extremely  ai)t  to  cause  a  spread 
of  the  inflammation.  When  the  tension 
on  the  abscess  cavity  is  relieved  by  the 
evacuation  of  the  pus,  its  walls  will  col- 
lapse, and  in  the  case  of  small  abscesses 
union  between  these  apposed  walls  will 
take  place  in  a  couple  of  days  by  the 
process  of  secondary  adhesion  (p.  1G2), 
anfl  a  superficial  ulcer  alone  will  remain.  In  such  cases  no  drain  need  be 
introduced  into  the  abscess  cavity;  but  in  the  vast  majority  of  instances 
it  is  important  to  introduce  between  the  lips  of  the  incision  some  sub- 
stance which  will  keep  them  from  uniting  until  healing  of  the  under- 
lying abscess  cavity  is  complete.  A  tube  of  soft  rubber,  commonly 
known  as  a  drainage  tube  (Fig.  8),  is  much  more  satisfactory  for 
this  purpose  than  is  any  substance,  such  as  gauze,  which  may  become 
clogged  with  the  discharging  pus,  and  thus  hinder,  instead  of  promote 
the  escape  of  pus  from  the  depths  of  the  cavity  as  healing  progresses. 
It  is  only  in  very  small  abscesses,  where  the  discharge  is  slight,  that 
a  gauze  drain  is  useful;  and  if  employed  in  other  cases,  where  it  may 
be  of  ^■alue  by  acting  as  a  tampon  to  check  oozing  of  blood  from 
the  walls  of  the  abscess  cavity,  it  is  better  to  use  a  tube  as  well;  or  a 


Fig.  S. — Drainage  tube  of  soft 
rubber,  with  numerous  eyelets. 


0'^ 


DISEASES  RESULTING  FROM  INFLAMMATION 


cigarette  drain  (Fig.  10)  may  be  employed.  In  small  abscesses  snffi- 
cient  drainage  may  often  be  procured  by  a  few  strands  of  silkworm 
gut  or  a  })iece  of  rubber  tissue. 


Fig.  9. — Deep  abscess  of  thigh;  through-and-through  drainage  by  rubber  tube, 
safety-pins  to  prevent  displacement  of  tube.     Episcopal  Hospital. 

The  dressings  of  an  abscess  (gauze)  will  absorb  the  discharges 
better  if  they  are  moist.  A  solution  of  sodium  chloride,  of  corrosive 
sublimate,  of  alcohol,  of  potassium  permanganate,  or  other  suitable 
antiseptic  may  be  used  for  this  purpose.  The  gauze  immediately 
next  the  dischargins;  sinus  should  be  well  crumpled  up  before  being 
applied;  laying  many  layers  of  flat  gauze  over  the  part  will  dam  up 
the  pus  in  the  abscess  cavity. 


Fig.  10. — Cigarette  drain,  made  by  covering  a  wick  of  gauze  with  rubber  tissue. 

Sinus  and  Fistula. — These  are  suppurating  tracts,  usually  due  to 
the  incomplete  healing  of  abscesses.  A  sinus,  as  pointed  out  at  p. 
48,  has  only  one  orifice,  since  its  other  extremity  ends  blindly  in 
the  former  abscess  cavity.^  A  fistula,  on  the  other  hand,  is  a  suppu- 
rating tract  with  at  least  two,  and  sometimes  several,  orifices,  which 
may  be  either  external,  internal,  or  both.  Sinuses  and  fistula  may 
be  kept  from  healing  by  the  action  of  neighboring  muscles  (as  in 
fistula  in  ana) ;  by  the  presence  of  some  foreign  body  (spicule  of  bone, 
ligature)  which  the  tissues  of  the  organism  cannot  destroy;  or  by 
the  constant  passage  of  the  secretions  of  the  part  through  the  abnor- 
mal opening  (salivary,  fecal,  or  urinary  fistula),  instead  of  through 
the  natural  channel. 

Treatment. — They  should  be  treated  by  removal  of  the  foreign 
body;  by  removing  the  obstruction  to  the  discharge  of  the  secre- 
tions; or  by  supporting  the  sides  of  the  sinus  with  adliesi\'e  plaster  or 
bandages  to  overcome  the  action  of  neighboring  muscles.  If  the  walls 
of  the  suppurating  tract  are  thickened  and  indurated,  they  should  be 

'  Such  a  sinus  often  is  called  a  "blind  fistula." 


ULCER  53 

stiiniihitt'd  \)\  the  use  (tt"  ("lustic  iiijcctioiis  (sil\ cr  nitrate,  /.iii<-  sulphate, 
etc.),  or  stiinulatiiif^  ointments  (dilute  niereuri<'  nitrate,  iclitliyol, 
iodin)  oil  a  rojx'  of  fiau/e;  l)y  curettintj  the  sinus  with  \'olkmann's 
sharj)  s])oon;  or  finally  by  slitting  the  tract  oi)eii  on  a  grooved  director, 
cauteriziiifr  it  with  caustic  potash  or  the  actual  cautery,  thus  producinj^ 
a  superficial  slouj^h  and  converting  the  sinus  into  an  ulcer,  and 
promoting  healing  from  the  bottom.  In  excessively  obstinate  cases 
a  cure  may  be  obtained  by  dissecting  out  the  entire  suj)purating 
tract,  and  uniting  the  parts  from  the  bottom  with  buried  absorbable 
sutures.  ]\Iany  chronic  sinuses,  especially  of  tuberculous  origin,  may 
be  cured  bv  the  injection  of  a  bismuth-vaselin  paste,  as  recommended 
by  Beck  (1908)  (see  Chapter  XV). 

Ulcer. — Ulceration  is  defined  as  the  molecular  death  of  a  part. 
Some  writers  distinguish  between  an  ulcer  and  a  granulating  wound, 
limiting  the  former  term  to  the  result  of  the  process  of  destruction 
known  as  ulceration,  and  therefore  denying  that  an  ulcer,  as  such, 
can  ever  heal;  maintaining  that  as  soon  as  healing  commences  the 
term  granulating  wound  should  be  adopted.  Certain  ulcers,  however, 
may  be  granulating  at  one  portion  of  their  surface,  while  still  actively 
ulcerating  at  another  point  (serpiginous  uJceration);  so  it  seems  fjetter 
while  acknowledging  the  distinction  between  ulceration  (molecular 
death)  and  granulation  (process  of  repair),  to  include  as  is  usually 
done,  both  granulating  and  ulcerating  surfaces  under  the  general 
heading  of  ulcer.  Park  tersely  defines  an  ulcer  as  "a  surface  which 
is  or  ought  to  be  granulating." 

The  repair  of  an  ulcer  occurs  by  granulation  and  cicatrization. 
The  formerly  ulcerating  surface  gradually  loses  its  inflamed  appear- 
ance; the  discharge  of  pus  lessens;  the  edges  of  the  ulcer  become 
firmer  and  more  clearly  defined;  and  granulations  are  seen  springing 
up  all  over  its  surface.  Soon  these  granulations  become  higher  than 
the  surrounding  skin;  often  they  become  exuberant,  forming  what  is 
known  as  "proud  flesh."  Aroung  the  edges  of  the  ulcer  the  neighbor- 
ing epithelium  proliferates,  gradually  covering  in  the  granulations, 
and  being  easily  distinguished  as  a  faint  blue  line  interposed  between 
the  healthy  skin  and  the  face  of  the  ulcer.  Occasionally  little  patches 
of  new  skin,  with  this  same  faint  bluish  tinge,  may  be  seen  in  the 
midst  of  the  granulations,  e\idently  arising  from  epithelial  cells 
which  have  survived  the  original  destructive  lesion.  As  these  changes 
progress  on  the  surface  of  the  ulcer,  beneath  its  surface  proceed  the 
changes  which  have  already  been  described  under  the  heading  Repair 
(p.  29);  that  is  to  say,  the  fibroblasts  become  converted  into  white 
fibrous  connective  tissue  (cicatrization),  and  as  a  consequence  the 
face  of  the  ulcer  contracts,  thus  decreasing  the  superficial  area  which 
must  be  covered  over  by  the  surrounding  epithelium.  This  con- 
traction, which  is  the  prime  characteristic  of  all  newh'  formed 
cicatricial  tissue,  is  most  noticeable  on  the  surface  of  the  body  in 
the  healing  of  ulcers  resulting  from  burns;  and  in  mucous  channels 
(urethra,  esophagus),  where  strictures  are  the  result. 


54  DISEASES  RESULTING  FROM  INFLAMMATION 

Certain  varieties  of  ulcer  are  descrihcd  l)y  systematic  writers. 
The  most  important  are: 

Simple  or  Healthy  Ulcer. — This  is  characterized  by  its  innate 
tendency  to  heal.  To  secure  prompt  healing  every  other  variety 
of  ulcer  must  be  converted  into  this  form.  Ordinary  incised  wounds 
healing  by  "second  intention,"  and  superficial  burns,  afford  good 
examples  of  a  healthy  ulcer.  This  ulcer,  if  not  too  large,  will  heal 
of  its  own  accord  if  it  be  protected  from  injury.  If  exposed  to  the 
air  after  the  granulations  are  well  formed,  a  scab  will  form  over  it, 
and  healing  under  the  scab  will  take  place  as  described  at  p.  162. 
Ordinarily  it  is  better  to  cover  the  ulcer  with  some  mild  ointment, 
spread  not  too  thickly  on  lint.  There  is  no  object  in  having  the 
ointment  spread  over  the  neighboring  healthy  skin  also;  indeed  to 
do  so  freciuently  causes  maceration  and  delays  healing. 

Inflamed  Ulcer. — This  is  one  in  wdiich  infection  is  still  progressing, 
the  reaction  of  the  tissues  being  insufficient  to  quell  the  invasion 
(Plate  I,  Fig.  3).  A  very  severe  form  of  inflamed  ulcer  is  the  slough- 
ing ulcer.  The  worst  form  of  all  is  phagedenic  ulcer,  usually  seen  only 
in  chancroidal  sores;  here  the  destruction  of  tissue  is  frightfully 
rapid,  and  nothing  short  of  thorough  cauterization  of  the  entire 
ulcerated  surfaces  will  suffice  to  check  the  phagedena.  In  ordinary 
cases  of  inflamed  ulcer,  confinement  to  bed,  with  elevation  of  the 
part,  the  local  use  of  antiseptics,  and  tonics  and  stimulants  inter- 
nalh',  may  l)e  necessary  to  arrest  ulceration. 

Weak  or  Edematous  Ulcer. — This  is  characterized  by  the  granu- 
lations being  large  and  flabby,  apparently  distended  with  serum, 
of  very  low  vitality,  and  easily  detached  in  masses  from  the  sur- 
face of  the  ulcer.  Usually  it  is  an  evidence  that  proper  care  of  the 
wound  has  been  neglected,  or  that  poultices  and  mild  ointments 
(zinc  oxide  and  boric  acid)  have  been  continued  too  long.  As 
granulations  contain  no  nervous  tissue,  no  hesitation  need  be  felt 
in  snipping  off  w^ith  scissors  the  exuberant  masses  of  proud  flesh; 
the  patient  will  not  feel  a  particle  of  pain.  Any  bleeding  is  readily 
checked  by  pressure  or  by  cauterization  with  the  stick  of  silver 
nitrate.  Then  more  stimulating  ointments  should  be  applied,  par- 
ticularly valuable  being  resin  cerate,  scarlet  red,  balsam  of  Peru, 
nitrate  of  mercury,  ichthyol,  etc. 

Neuralgic  or  Irritable  Ulcer. — This  is  usually  of  small  size,  placed 
at  the  ankle,  below  or  near  to  one  of  the  malleoli,  and  is  characterized 
by  the  intense  pain  experienced  by  the  patient.  The  skin  margins 
are  usually  thickened,  the  ulcer  has  little  or  no  discharge,  its  surface 
being  glazed  and  exquisitely  sensitive.  Frequently  it  is  evident  that 
the  ulcer  involves  the  terminal  filaments  of  some  sensory  nerve, 
especially  the  musculocutaneous  or  the  internal  saphenous  nerves 
at  the  ankle  (Fig.  11).  If  rest  in  bed,  with  elevation  of  the  part,  and 
cauterization  of  the  base  of  the  ulcer  fails  to  relieve  pain,  the 
affected  nerve  some  three  to  six  inches  above  the  ulcer  may  be 
stretched  or  excised  (Hilton,  1877). 


VLCER 


55 


Indolent  or  Callous  Ulcer. — This  is  the  most  frequent  form  of  "le^ 
ulcer,"  usually  occurriiij^  in  achilts,  on  the  lower  half  of  the  le^,  and 
on  the  anterior  or  fihular  aspect.  The  surface  of  the  ulcer  is  dry, 
and  sometimes  j^la/.ed;  the  granulations  are  low  and  ill-formed;  the 
edges  are  hypertrophied  and  dense,  and  give  to  the  surface  of  the 
ulcer  a  depressed  or  concave  appearance  (Fig.  12).  As  cure  depends 
uj)on  contraction  of  the  base  of  the  ulcer,  and  on  concentric  cicatri- 
zation proceeding  from  its  edges,  it  is  evident  that  destruction  of  the 
callous  margins  is  the  first  step  in  this  direction.  These  margins 
surround  the  ulcer  like  a  cartilaginous  ring,  and  by  their  lack  of 
elasticity  and  by  their  very  bulk  prevent  contraction  of  the  ulcer's 
base;  moreover,  the  surrounding  epithelium  appears  indolent  and 
unable  to  proliferate  so  as  to  cover  in  the  granulations.     The  ulcer 


Fig.  11. — Neuralgic  or  irritable  ulcer  in  a 
woman,  aged  forty-five  years.  Duration  four 
weeks.     Episcopal  Hospital. 


Fii;.  12. — Indolent  or  callous  ulcer> 
of  the  leg.     Episcopal  Hospital. 


usually  is  due  to  some  trivial  injury,  repair  of  which  becomes 
impossible  from  the  necessity  of  the  patients  continuing  their  occupa- 
tions as  means  of  livelihood,  and  because  of  some  constitutional 
condition  (obesity,  arteriosclerosis)  which  interferes  with  the  normal 
circulation  of  the  blood  and  lymph  in  the  part.  If  the  patient  be 
put  to  bed  and  the  callous  margins  of  the  ulcer  be  softened  by 
poultices  or  simple  wet  dressings,  the  ulcer  usually  will  soon  be  con- 
verted into  one  of  the  healthy  type,  and  cure  will  soon  be  brought 
about.  As  soon,  however,  as  the  patient  resumes  his  occupation, 
the  old  ulcer  is  apt  to  reappear  whenever  the  skin  is  bruised. 
It  is  important,  on  this  account,  to  take  great  pains  to  avoid 
injury  and  to  maintain  the  skin  in  good  condition,  when  once  the 
ulcer  has  healed.    Scrupulous  cleanlinesss  should  be  enjoined;  and 


ofi 


DISEASES  RESULTING  FROM  IXFLAMMATIOX 


wliere  a  tendency  to  edema  of  the  leg  exists,  much  l)enefit  may 
be  gained  from  the  use  of  an  elastic  bandage,  which  usually  is 
preferable  to  an  elastic  stocking.  But  it  may  be  impossible  for 
the  patient  to  be  laid  up  in  bed  for  some  weeks,  which  is  the 
shortest  time  in  which  a  cure  may  be  anticipated;  yet  even  with- 
out the  advantages  of  rest  in  the  recumbent  position,  it  is  by  no 
means  impossible  to  bring  about  a  cure  of  the  ulcer.  Poultices  and 
wet  dressings  may  be  applied  while  the  patient  continues  at  his 
work,  and  when  the  margins  of  the  ulcer  have  become  reasonably 
soft,  it  may  be  strapped  with  adhesive  plaster,  thus  supporting  the 
edges,  preventing  a  re-accumulation  of  blood  and  lymph  in  the  parts, 
and  mechanically  promoting  healing  of  the  base.    The  straps  should 

be  an  inch  or  an  inch  and  a  half 
wide,  long  enough  to  encircle  about 
three-fourths  of  the  limb  when 
obliquely  applied ;  and  are  to  be  put 
on  from  below  upward  in  an  imbri- 
cated manner,  two  at  a  time,  thus 
drawing  the  edges  of  the  ulcer  to- 
gether as  the  two  straps  are  crossed 
(Fig.  13).  The  strapping,  which 
should  start  an  inch  or  so  below 
the  tilcer,  and  continue  for  an  equal 
distance  above  its  upper  margin, 
should  be  covered  in  by  a  firm 
muslin  bandage,  extending  from  the 
patient's  toes  to  his  knee.  This 
dressing  may  remain  in  place  for 
from  five  days  to  a  week;  when  it 
is  to  be  removed,  the  skin  should 
be  washed  with  turpentine,  the 
edges  of  the  ulcer  (just  within  the 
blue  Ime  of  new  skin)  touched 
with  the  solid  stick  of  silver  nitrate, 
and  the  straps  again  applied  and 
covered  in  with  a  firm  bandage 
as  before.  ^Mien  the  ulcer  assumes  the  character  of  a  simple  or 
healthy  ulcer,  strapping  may  be  discontinued,  and  ointments  may 
by  applied;  but  frequently  the  ulcer  will  heal  under  the  use  of  straps 
alone.  The  results  of  this  treatment,  when  it  is  carefully  carried  out, 
are  remarkable:  ulcers  which  have  been  open  for  a  year  or  more, 
and  on  which  all  manner  of  salves  have  been  tried,  may  be  completely 
healed  within  comparatively  few  weeks.  It  is  usually  best  for  the 
patient  to  continue  to  keep  the  leg  bandaged  for  a  long  time  after 
apparent  cure  has  been  obtained,  since  relapses  are  frequent.  In 
the  rare  cases  where  rest  in  bed,  poultices,  and  strapping,  fail  to  cure 
an  indolent  ulcer,  its  conversion  into  a  healthy  ulcer  sometimes 
may  be  accelerated  by  dividing  its  callous  margin  by  several  radiating 


Fig.  1-3. — Strapping  a  leg  ulcer. 
Episcopal  Hospital. 


ULCER 


57 


incisions,  or  vvvu  l)y  iiiakiiit;'  criss-cross  incisions  extending'  llironfj;h 
the  base  of  the  nicer  and  its  eallons  niaruin  on  l)otli  sides.  Or  the 
nk'er  may  he  nn(kT-ent  I'rom  the  sides,  separatini^;  its  base  c()nii)letely 
from  tlie  (k'ep  fascia.  Skiit  gnij'tutg  (p.  '2'2'A)  lias  heen  employed  to 
hasten  the  cicatrization  of  these  ulcers,  but  without  much  success. 
Formal  plastic  operations  (p.  225)  occasionally  have  been  adopted, 
but  with  no  very  jicrmanent  results.  A  great  many  of  these  callous 
leg  ulcers  are  due  to  the  unsuspected  presence  of  syphilis.  Tlie  typical 
syphUiiic  leg  ulcer  (Fig.  14)  is  situated  above  the  middle  of  the  leg, 
is   characteristically  round,  is  seldom  very  ])ainfu],  and  yields  with 


Fig.  14. — Syphilitic  ulcer  of  leg,  male, 
aged  twenty-four  year.s.  Following  "ru- 
pia"  of  six  weeks' duration.  Completely 
healed  under  anti-syphilitic  treatment  in 
three  weeks.     Episcopal  Hospital. 


Fiu.  15. — Varicose  leg  ulcer. 
Episcopal  Hospital. 


remarkable  facility  to  the  administration  of  mercury  and  the  iodides. 
But  in  many  of  the  callous  ulcers  in  which  no  definite  history  of 
syphilis  can  be  obtained,  much  improvement  often  follows  the  adminis- 
tration of  potassium  iodide  alone  or  with  mercury.  In  almost  all 
cases  of  leg  ulcer  of  long  duration  the  tibia  immediately  beneath 
the  seat  of  disease  becomes  thickened;  but  in  the  case  of  syphilitic 
ulcers  there  is  sclerosis  of  the  bones,  and  as  pointed  out  by  Coues 
the  diagnosis  of  syphilitic  leg  ulcer  usually  may  be  confirmed  by  a 
skiagraj)h.  In  very  exceptional  cases  the  callous  ulcer  is  absolutely 
incurable.    But  life  with  an  incurable  leg  ulcer  is  by  no  means  impos- 


58 


DISEASES  RESULTIXG  FROM  IXFLAMMATIOX 


sible;  indeed,  many  persons  live  for  fifteen  to  twenty  years,  or  longer, 
with  unhealed  le*;  ulcers,  and  are  able  to  lead  very  active  lives.  It 
is  only  in  the  rarest  instances,  therefore,  that  amputation  is  justi- 
fiable; for  the  risk  to  life  usually  is  much  less  from  an  unhealeti  leg 
ulcer  than  from  amputation. 

Varicose  Ulcer. — This  is  one  associated  with  varicose  veins  (Fig.  15). 
It  is  difficult  to  heal,  sometimes  is  attended  by  alarming  hemorrhages, 
and  frequently  incapacitates  the  patient.  The  use  of  elastic  bandages, 
hot  baths,  gentle  massage,  etc.,  by  reducing  the  swelling,  and  improv- 
ing the  circulation  of  the  limb,  sometimes  will  bring  about  a  cure, 
or  at  least  will  keep  the  patient  in  comfort.  If  palliative  measures 
fail,  excision  of  the  affected  veins  may  be  done;  but  the  operation 
is  one  of  more  risk  than  when  no  ulcer  exists,  and  sliould  not  be 
undertaken  lightly.  It  should  never  be  done  in  the  presence  of  active 
phleliitis;  and  if  the  veins  are  thrombosed  as  the  result  of  a  former 
phlef)itis,  they  should  be  divided  through  healthy  portions  above 
the  limit  of  tlie  clot. 

Warty  Ulcer. — Under  this  name  Marjolin  (1846)  described  a  form 
of  ulcer  which  of  late  years  usually  has  been  regarded  as  due  to 

malignant  clianges.  It  is  not  correct,  how- 
ever, to  give  the  name  of  Marjolin  to  every 
ulcer  which  undergoes  malignant  transfor- 
mation, as  his  original  description  applied 
merely  to  the  clinical  appearance  of  tlie  ulcer, 
as  if  covered  with  warts.  Fig.  16  represents 
a  typical  warty  ulcer,  whicli  healed  rapidly 
under  appropriate  treatment.  When  of  long 
standing  a  malignant  ulcer  whose  surface  is 
warty  frequently  is  found  to  involve  the 
bone,  which  is  the  seat  of  caries,  perhaps  due 
to  a  primary  sarcoma  of  bone,  or  possibly 
involved  secondarily  by  a  surface  epithelioma. 
If  the  warty  ulcer  is  malignant,  it  is  much 
safer  to  amputate  tlie  limb  than  to  attempt 
excision;  but  if  the  malignant  ulcer  is  of  the 
heel  (I  have  seen  two  cases  following  burns 
in  this  situation),  resection  may  properly  be 
done,  with  restoration  of  tlie  foot  by  the 
method  of  ^Mikulicz,  if  the  patient  refuses 
amputation. 

Gangrene  (sphacelus, mortification,  slough- 
ing) is  a  term  used  to  describe  the  process 
of  death  of  the  soft  parts,  or  of  an  entire 
extremity  with  its  contained  bone,  when  this  death  occurs  in  mass; 
necrosis,  though  usually  confined  in  its  application  to  death  of  bone,  is 
occasionally  employed  to  describe  the  death  of  soft  parts  at  a  depth 
from  the  surface,  where  no  marked  inflammatory  phenomena  are 
present,  the  resulting  necrotic  masses  corresponding  very  closely  to 


Fig.  16. — Warty  ulcer  of 
Marjolin  connected  with 
periosteitis  eight  months 
after  typhoid  fever.  From 
direct  injury.  Aged  fourteen 
years.    Episcopal  Hospital. 


GANGRENE 


59 


the  sequestra  met  with  in  necrosis  of  l)()ne.  In  ulceration,  tlie  dead 
parts  are  cast  otV  in  tlie  form  of  pus  (liquefaction  necrosis),  and 
moleriihir  drafli  of  the  tissues  is  sai(l  to  occur;  whereas  in  f^anj^rene 
(molar  dnttli)  the  i)arts  cast  o(f  (sloughs)  are  of  such  size  as  to  he 
clearly  visible  to  the  naked  eye. 

The  causes  of  gangrene  are  either  direct  (as  in  pulpefaction  of  a 
limb  by  crushing  force,  destruction  by  caustics,  by  heat  or  cold,  by 
bacterial  toxins,  etc.),  or  indirect,  from  interference  with  the  vascular 
supply.    One  of  the  most  extensive  cases  of  sloughing  I  ever  saw  was 

in  a  lad  of  16  years,  whose  whole  lower 

extremity  had  passed  through  cog-wheels; 
though  there  was  no  injur}-  to  the  ^'ascu- 
lar  supply  of  the  limb,  the  pressure  of  each 
cog  produced  immediate  death  of  the  area 
it  crushed,  and  it  was  over  ten  weeks  be- 
fore the  sloughs  had  all  separated  and  the 
resulting  ulcers  healed.  The  appearance 
of  the  cicatrices  six  years  after  the  accident 
is  shown  in  Fig.  17.  Injuries  which  in  a 
normal  state  of  health  would  cause  only 
trivial  lesions,  when  complicated  by  vascu- 
lar o})struction  or  constitutional  disease 
mav   result  in   verv  extensive   sloughing 


Fig.  17. — Cicatrices  from 
sloughing,  .six  years  after  in- 
jury (cog-wheels).  Episcopal 
Hospital. 


Fig.  18. — Gangrene  following  application  for 
twenty-four  hours  by  patient's  mother  of  carbolic 
acid  dressing.     Episcopal  Hospital. 


or  gangrene.  The  same  degree  of  inflammatory  infiltration,  which  in 
the  subcutaneous  tissues  would  be  harmless,  when  occurring  beneath 
the  palmar  fascia  or  other  dense  fibrous  membrane  may  produce  such 
a  choking  off  of  the  ])lood-supply  as  to  cause  extensive  necrosis  of  the 
structures  involved.  In  the  old,  or  in  younger  persons  with  marked 
arteriosclerosis,  so-called  senile  gangrene  may  follow  trifling  injuries, 
or  may  be  caused  by  gradual  occlusion  of  the  arteries  without  external 
injury.  In  diabetics  there  is  a  special  tendency  to  necrotic  processes, 
among  the  mildest  of  which  are  furuncles  with  their  central  slough  or 
core.  In  patients  suffering  from  ergotism,  gangrene  of  the  fingers  or 
toes,  perhaps  symmetrical,  is  a  not  infrequent  phenomenon.  It  is  usually 
preceded  by  premonitory  symptoms,  such  as  formication,  cramps, 


60  DISEASES  RESULTING  FROM  INFLAMMATION 

local  asphyxia,  etc.  Certain  lesions  of  the  nerwms  sysfcin,  jirobably 
through  vaso-motor  changes,  may  induce  hed-sores,  siougliing,  etc., 
in  an  alarmingly  short  space  of  time.  The  so-called  perforating  ulcer 
of  the  foot  (p.  261),  probably  is  due  to  a  similar  change,  though 
arteriosclerosis  is  usually  a  factor  also.  Carbolic  acid  gangrene 
(Fig.  18)  results  from  the  direct  caustic  action  of  the  solution 
employed,  and  often  follows  the  use  of  a  weak  solution  which 
becomes  concentrated  by  evaporation. 

Bacteria  are  not  a  necessary  accompaniment  of  gangrene;  their 
presence  usually  is  incidental.  In  a  few  rare  instances,  bacterial 
toxins  are  believed  to  be  the  immediate  cause  of  gangrene  by  causing 
endarteritis,  phlebitis,  and  thrombosis.  This  is  probably  the  case 
in  noma  (p.  63).  Emphysematous  gangrene  (p.  65)  is  due  to  infec- 
tion with  gas-producing  bacteria,  the  production  of  gas  preceding 
the  development  of  gangrene.  Saprophytic  bacteria  usually  invade 
tissues  which  have  already  become  gangrenous,  and  produce  the 
malodorous  gases  characteristic  of  putrefaction. 

There  are  two  main  varieties  of  gangrene,  the  moisi  and  the  dry, 
dependent  in  large  measure  upon  the  amount  of  moisture  in  the 
part  when  the  vascular  current  is  occluded,  and  on  the  amoimt  of 
evaporation  which  takes  place.  ]\Ioist  gangrene  usually  is  due  to 
venous  obstruction  (thrombosis,  pressure  of  tumors,  splints,  bandages, 
etc.);  it  is  occasionally  seen,  however,  after  sudden  occlusion  of  the 
main  artery  of  a  limb  (embolism,  wounds,  ligation,  etc.),  if  the  venous 
blood  already  present  remains  in  the  part.  Dry  gangrene,  of  which 
the  senile  form  is  typical,  usually  is  due  to  slowly  progressing  arterial 
occlusion,  the  parts  deprived  of  vascular  supply  becoming  mummi- 
fied.   Diabetic  gangrene  is  usually  rather  dry. 

Symptoms. — When  a  part  which  has  been  inflamed  becomes  gan- 
grenous, the  color  fades  into  bluish  green  or  purple,  and  finally  into 
black;  the  pain,  at  first  burning  and  intolerable,  suddenly  ceases; 
the  affected  area  becomes  numb  and  senseless;  the  cuticle  is  raised  in 
bullae  filled  with  bloody  or  purulent  fluid;  the  part  instead  of  being 
tense  feels  doughy;  and  the  local  temperature  falls.  There  is  gradually 
formed,  at  the  point  where  the  resistive  powers  of  the  individual 
are  sufficient  to  overcome  the  destructive  lesions  producing  the 
gangrene,  a  line  of  demarcation,  indicated  by  a  red  line  encircling 
the  gangrenous  structures.  In  this  region  the  usual  phenomena  of 
inflammation  occur,  and  as  this  process  continues,  a  line  of  granula- 
tions is  formed,  known  as  the  line  of  separation.  By  the  gradual 
increase  of  these  granulations  the  dead  tissues  are  pushed  away,  as 
it  were;  and  unless  assisted  by  the  surgeon  this  tedious  process  will 
continue  until  the  entire  gangrenous  area  is  extruded  in  the  form  of  a 
slough.  An  entire  limb  may  be  amputated  spontaneously  in  this 
way. 

During  the  formation  of  the  line  of  demarcation,  there  is  often 
considerable  constitutional  disturbance,  due  to  the  sapremia  caused 
by  absorption  from  the  imperfectly  isolated  gangrenous  area;  and 


TREATMENT  OF  GANGRENE  61 

even  during  the  process  of  gramilation,  before  the  slough  is  cast  off, 
the  patient  is  constantly  exposed  to  infection  from  the  decayed  struc- 
tures. These  constitutional  symi)toms  usually  are  much  less  or 
altogether  absent  in  dry  gangrene,  where  the  process,  as  already 
mentioned,  resembles  munnnification. 

Treatment. — The  separation  of  sloughs  sometimes  seems  to  be 
hastened  b\-  poulticing  the  part.  The  charcoal  poultice  is  particularly 
useful  in  these  cases,  as  it  lessens  the  odor  by  absorbing  tlie  gases. 
The  yeast  poultice  also  acts  well.  \  arious  chemical  digestants  have 
been  used,  in  the  eti'ort  to  aid  nature  in  dissolving  the  sloughs;  but 
little  more  is  thus  accomplished  than  by  simply  kee{)ing  the  parts 
clean  and  protecting  them  from  outside  infection.  In  the  case  of 
extensive  gangrene,  tlie  most  important  thing  is  to  prevent  infection; 
amputation  will  surely  be  required  later,  but  if  infection  is  absent 
the  surgeon  can  safely  postpone  it  until  some  indication  is  present 
of  the  le^'el  at  which  it  must  be  done.  Early  amputation  is  often 
needlessly  high.  In  moist  gangrene  constant  irrigation  with  dilute 
antiseptics  is  one  of  the  surest  methods  of  preventing  infection;  in 
dry  gangrene  it  usually  is  sufficient  to  keep  the  parts  well  covered 
with  sterile  cotton.  Periodical  baking  of  the  limb,  as  in  chronic 
joint  affections,  is  also  of  great  service.  In  senile  gangrene,  where 
only  one  or  two  toes  are  affected,  formal  amputation  may  never  be 
required,  as  nature  will  be  able  to  remove  the  slough  at  one  of  the 
phalangeal  joints  with  less  constitutional  disturbance  than  w^ould  be 
caused  by  an  operation ;  if  the  gangrene  extends  beyond  the  toes,  how- 
ever, amputation  should  be  done  above  the  ankle;  and  if  it  extends 
above  the  ankle,  amputation  through  the  lower  third  of  the  tbigli 
should  be  done :  it  is  not  advisable  to  wait  for  the  line  of  demarcation, 
and  to  amputate  at  low^r  points  than  those  named  almost  certainly 
would  expose  the  patient  to  recurrence  of  gangrene  in  the  stump. 
To  determine  the  level  at  w^hich  amputation  should  be  done  Lejars 
employs  (1909)  the  "comparative  hyperemia"  test:  the  limb  is 
elevated,  an  elastic  bandage  is  applied,  exsanguinating  it,  and  exsan- 
guination  is  maintained  by  an  Esmarch  band  for  five  or  ten  minutes 
after  the  elastic  bandage  is  removed;  the  hyperemic  blush  which 
follows  the  removal  of  the  Esmarch  band  will  extend  only  so  far 
as  healthy  circulation  is  present,  and  amputation  may  be  done  safely 
at  this  point.  In  the  healthy  limb  the  hyperemic  blush  extends  to 
the  toes.  Arterio-venous  anastomosis  ("  reversal  of  the  circulation") 
as  a  method  of  treatment  for  gangrene,  is  discussed  at  p.  2-11.  In 
many  cases  of  senile  gangrene  it  is  evident  that  any  operation  would 
only  hasten  the  fatal  termination;  under  such  circumstances  of  course 
only  palliative  treatment  is  admissable.  In  diabetic  gangrene  (Fig.  19) 
amputation  is  not  to  be  recommended  until  sepsis  threatens.  De  Witt 
Stetten  (1912)  has  shown  .the  remarkable  success  which  attends 
judicious  conservative  treatment,  especially  sterilization  of  the  limb 
by  repeated  baking.  Amputation  for  gangrene  following  frost-bite 
and  bums,  sht)uld  not  be  done  until  the  line  of  demarcation  has 


62 


DISEASES  RESULTING  FROM  INFLAMMATION 


formed,  as  it  is  impossible  to  know  heforeliand  at  what  le\'el  the 
limb  must  be  removed.    In  the  case  of  gangrene  resulting  from  local 

injury  due  to  crushes,  compound 
fractures,  etc.,  amputation  should 
be  done  as  soon  as  gangrene  is 
manifest;  it  is  impossible  to  pre- 
vent infection  in  such  cases,  and 
delay  in  resorting  to  amputation 
usually  will  cost  the  patient  his 
life.  When  gangrene  is  due  to 
arterial  occlusion  (embolism,  ligation 
for  wound),  amputation  should  be 
done  at  the  site  of  the  occlusion, 
as  soon  as  gangrene  is  evident 
(Guthrie,  1815);  but  in  the  case 
of  injury  to  the  superficial  femoral 
artery,  amputation  below  the  knee 
usually  is  sufficient,  and  occasion- 
ally in  the  upper  extremity  a 
collateral  circulation  may  be  estab- 
lished. 

Special  Forms  of  Gangrene. — 
Decubitus  or  bed-sore  (Fig.  21)  is 
due  to  necrosis  of  the  skin  and 
subcutaneous  tissues  from  long  continued  pressure  on  bony  promi- 
nences in  those  confined  to  bed,  especially  in  those  with  debilitating 
diseases  or  in  a  helpless  condition.  Favorite  sites  are  over  the  sacrum 
and  sacro-iliac  joints  (Fig. 


Fig.  19. — Diabetic  gangrene.  Aged 
seventy-four  years.  Duration  two 
months.  Healed  under  conservative 
treatment.      Episcopal    Hospital. 


re- 


22);  but  any  point 
ceiving  constant  pressure 
(occiput,  scapulae,  elbows, 
heels,  malleoli)  may  de- 
velop bed-sores.  They 
usually  may  be  prevented 
by  proper  care  of  the  skin, 
allowing  no  folds  or  creases 
in  the  bed-clothes  (the  pa- 
tient may  lie  on  a  blanket 
instead  of  a  sheet),  with 
frequent  changes  of  posi- 
tion, and  use  of  air-pillows, 
rings,  water-beds,  etc. 
Scrupulous  cleanliness  is 
most  important,  keeping 
the  skin  dry  (in  cases  of 
involuntary  dejections)  and  protecting  it  after  use  of  stimulating 
lotions  by  dusting  powders  or  soap  plaster.  The  same  measures  are 
important  in  the  treatment  of  a  bed-sore  when  once  it  has  formed. 


Fig.  20. — Dry  gangrene  from  embolism;  male, 
aged  forty  years.  In  December  embolus  lodged  in 
brain,  causing  right-sided  hemiplegia;  in  March 
(three  weeks  before  photograph)  embolus  lodged  in 
right  popliteal  artery.  Death  a  few  weeks  later. 
No  operation.    Episcopal  Hospital. 


NOMA 


63 


TIk'  sl(tui;li  should  iu»t  \)v  cut  ;i\vii\'  until  it  is  (|uito  loose,  and  tlic 
undorlyiui;-  ulcer  should  he  dressiul  with  rather  stinuilatiug-  ointments. 
Constitutional  treatment  never  sliould  l)e  nefi;lected.  (J<>t  tlie  patient 
out  of  bed  as  soon  as  possible.  Lon^jj  continuance  of  a  hirge  bed-sore 
is  a  tremendous  drain  on  the  vitality  and  not  infrequently  is  an 
indirect  eause  of  death  (exhaustion,  sepsis,  hemorrhage). 


Fig.  21. — Decubitus  or  bed-sore,  in  a 
patient,  aged  seventy-eight  years;  duration 
two  months.  The  sloughs  have  been  cut 
away.     Episcopal  Hospital. 


Fig.  22. — Cicatrices  from  bed- 
sores, in  patient,  aged  twenty  years, 
developing  during  typhoid  fever  five 
years  ago.     Episcopal  Hospital. 


Hospital  Gangrene  {Sloughing  Phagedena,  Pourriture  cV  Hopital). — 
This  scourge  of  military  hospitals  in  former  years  probably  is  due  to 
a  specific  microbe.  Its  clinical  causes  are  crowding,  bad  ventilation, 
and  generally  unhj'gienic  conditions.  It  is  now  almost  unknown. 
It  arose  only  in  wounds,  though  the  wounds  sometimes  were  mere 
abrasions.  The  surface  of  the  wound  became  dry,  was  covered  with 
"a  pulpy,  ashen  slough,"  and  the  circular  shape  and  cup-like  depres- 
sion of  the  wound  were  considered  characteristic.  By  attention  to 
hygiene  its  development  usually  may  be  prevented.  It  is  most 
successfully  treated  by  strong  antiseptics  (bromin,  iodin)  and  scrupu- 
lous cleanliness.  Patients  affected  should  be  isolated.  x'Ymputation 
is  scarcely  ever  necessary. 

Noma. — Noma  is  a  gangrenous  affection,  almost  exclusiA'ely  con- 
fined to  childhood,  usually^  following  the  exanthemata  (especially 
measles)  or  typhoid  fever.  Various  bacteria  have  been  found  by 
different  observers,  certain  forms  of  leptothrix  being  those  most 
frequently  present.  As  mixed  infection,  including  saprophytes, 
almost  always  exists,  the  etiological  relation  of  any  one  form  is  diffi- 
cult to  determine.  The  disease  affects  the  mouth  (Gangrenous 
Stornatitis,  Cancrum  Oris)  and  the  external  genitals  {Noma  Pudendi), 
especially  the  genitals  of  female  children.  The  ear  and  the  rectum 
have  also  been  affected.  Whether  in  the  mouth  or  the  genitals,  the 
disease  usuallv  starts  on  the  mucous  membrane,  and  in  an  incrediblv 


64 


DISEASES  RESULT  I XG  FROM  INFLAMMATION 


short  space  of  time,  perhaps  three  or  four  hours,  a  gangrenous  ulcer  an 
inch  or  more  in  diameter,  may  be  i)resent.  The  first  thing  to  attract 
attention  is  often  a  shiny  red  spot  on  the  exterior  of  the  cheek,  the 
gangrenous  ulcer  having  nearly  perforated  before  being  discovered. 
But  if  this  complication  be  kept  in  mind  the  disease  may  be  detected 
at  an  earlier  stage  from  fetor  of  the  breath,  disinclination  for  food, 
etc.,  which  will  lead  the  nurse  or  attending  physician  to  examine 
the  mouth.  The  constitutional  symptoms  are  slight,  and  the  child, 
though  listless,  may  continue  to  play  with  its  toys  until  the  hour 
of  death.  The  alveolus  may  be  involved,  the  cheek  perforated,  and 
frightful  destruction  produced  in  a  very  short  space  of  time. 

Treat )ncnf  should  be  prompt  and  vigorous;  the  child  being  anesthe- 
tized, a  mouth  gag  should  be  introduced,  the  cheek  everted,  scraped 

with  Volkmann's  spoon,  and 
the  base  of  the  ulcer  thoroughly 
cauterized  with  fuming  nitric 
acid  applied  by  a  stout  stick; 
or  acid  nitrate  of  mercury  may 
be  used.  If  the  cheek  has  been 
perforated,  it  is  best  to  exer- 
cise the  whole  ulcer;  and  it 
may  be  necessary  to  excise  a 
couple  of  inches  of  the  alveo- 
lus (Fig.  23) .  Free  stimulation 
must  be  employed  afterwards 
and  the  mouth  kept  constantly 
clean  by  the  use  of  suitable 
washes.  Death  from  exhaus- 
tion, bronchopneumonia,  or 
pyemia,  is  the  rule.  The  mor- 
tality varies  from  70  to.  95  per  cent.  If  the  child  recovers,  a  plastic 
operation  may  be  necessary  to  restore  the  cheek.  Similar  treatment 
should  be  adopted  in  the  case  of  Noma  Pudendi,  which  is  a  much 
rarer  affection. 

Aiahum. — This  is  a  rare  tropical  disease,  generally  ending  in 
gangrene,  which  usually  is  dry,  affects  the  toes,  and  is  almost  exclu- 
sively confined  to  the  negro  race.  Unna,  according  to  Freeman 
(1906),  regards  it  as  a  circular  scleroderma  which  strangulates  the 
toe.  The  affected  parts  appear  as  if  tightly  constricted  by  a  string, 
and  spontaneous  amputation  occurs  after  the  lapse  of  an  indefinite 
time.    The  disease  may  extend  over  ten  years. 

Sjnnmetrical  Gangrene. — Symmetrical  gangrene  is  due  to  an  obscure 
affection  of  the  nervous  system  (Raynaud's  disease),  causing  local 
asphyxia  of  symmetrical  portions  of  the  body,  especially  fingers 
and  toes,  probably  from  \'ascular  spasm.  As  a  rule  only  small  super- 
ficial sloughs  are  formed.  The  symptoms  are  tingling,  numbness, 
etc.  Intermittent  claudication  may  be  an  early  sign.  Little  can 
be  done  in  the  way  of  treatment,  except  tonics  and  hygienic  measures. 


Fig.  2-3. — Xoma  following  inta.^lt.-,  iw  a 
child,  aged  three  years;  duration  one  week. 
The  gangrenous  parts  have  been  excised. 
Death.     Children's  Hospital. 


EMPHYSEMATOUS  GANGRENE  65 

Massage  and  hot  baths,  locally,  may  be  of  benefit.  The  patients 
usually  recover,  though  successive  attacks  are  usual.  Noesske  (1909) 
incises  the  finger  tip  down  to  the  bone  and  applies  a  cupping  glass; 
his  theory  is  that  the  gangrene  is  due  to  stagnation  of  blood  from 
venous  obstruction;  and  that  if  a  constant  fresh  su])ply  of  arterial 
blood  is  obtained  by  cupping,  gangrene  may  be  prevented  until  the 
spasm  ceases. 

Emphysematous  Gangrene  {Traumatic  or  Spreading  Gangrene, 
Gangrene  Foudroyante). — Under  this  title  three  distinct  affections 
are  sometimes  grouped:  (1)  True  empliysematous  gangrene,  a  form 
of  gangrene  due  to  infection  with  various  gas-producing  bacteria; 
(2)  JNIalignant  Edema,  caused  by  a  specific  bacillus;  and  (3)  Ordinary 
forms  of  gangrene,  in  which  putrefactive  changes  are  accompanied 
by  gas  production.  The  third  form  clearly  does  not  belong  here; 
but  as  the  B.  oedematic  maligni  is  a  gas-forming  microbe,  and  as  it 
is  usually  impossible  to  distinguish  clinically  infection  due  to  it  from 
that  due  to  numerous  other  gas-forming  microorganisms,  there  is  no 
good  reason  why  it  should  not  be  included  in  this  section.  When 
not  due  to  the  bacillus  of  malignant  edema,  emphysematous  gangrene 
may  be  caused  by  infection  with  the  Bacillus  aerogenes  capsulatus, 
B.  proteus  vulgaris,  or  B.  coli  communis,  especially  that  first  nanjied. 
The  condition  is  almost  invariably  observed  only  as  a  complication 
of  severe  compound  fractures  or  lacerated  wounds,  but  occasionally 
has  followed  punctured  wounds  or  even  mere  abrasions.  On  the 
third  or  fourth  day  after  the  injury  the  wounds  do  not  discharge  as 
freely  as  might  be  expected,  and  careful  palpation  will  detect  emphy- 
sematous crackling,  which  extends  with  alarming  rapidity  along 
the  subcutaneous  tissues  (especially  along  the  course  of  the  large 
vessels),  and  may  involve  even  the  muscles.  The  skin  becomes 
dusky,  purplish,  and  mottled  in  appearance,  and  at  a  later  stage  the 
vesications  and  bullae,  so  characteristic  of  fermentative  changes  in 
already  mortified  parts,  may  develop.  Incisions  into  the  swollen 
and  boggy  tissues  give  exit  to  froth}'-  fluid  and  malodorous  gases. 
The  patient  sinks  into  a  typhoid  state;  there  is  little  fever;  the  pulse 
may  be  slow ;  and  death  ensues  a  short  time  after  the  infection  reaches 
the  .trunk.  The  entire  course  of  the  disease  may  extend  over  only 
six  or  eight  hours.  The  safest  treatment  is  immediate  amputation, 
high  above  the  limit  of  the  affected  tissues.  When  this  is  impos- 
sible, free  incisions  should  be  made,  the  limb  should  be  placed  under 
constant  antiseptic  irrigation,  hydrogen  peroxide  being  preferred  as 
the  gas-forming  bacteria  are  anaerobic;  free  stimulation  should  be 
administered,  and  everything  possible  should  be  done  to  obviate  the 
tendency  to  a  fatal  termination.  If  amputation  be  done,  the  incisions 
should  pass  through  absolutely  healthy  tissues,  and  the  stump  should 
be  freely  drained,  and  frequently  dressed  to  detect  the  first  evidence 
of  recurrence  in  the  flaps.  I  have  seen  only  two  cases  of  emphy- 
sematous gangrene:  in  the  first  case,  under  Dr.  Neilson's  care  at  the 
Episcopal  Hospital,  it  followed  compound  fracture  of  the  elbow  in 
5 


66  DISEASES  RESULTIXG  FROM  I X  FLAM  M  ATI  OX 

an  old  man;  the  gangrenous  emphysema  invaded  the  chest  in  three 
hours  from  its  first  appearance,  before  amputation  could  be  done, 
and  death  followed  a  few  hours  later.  In  the  second  patient  (Fig.  24), 
in  Dr.  Frazier's  service  at  the  Episcopal  Hospital,  a  lad  of  sixteen, 
whose  arm  had  been  caught  in  revolving  rollers  and  the  skin  squeezed 
off  from  above  the  elbow  to  the  wrist,  I  successfully  removed  the 
arm  at  the  shoulder-joint  (Fig.  163)  a  few  hours  after  the  emphysema 
spread  beyond  the  circular  slough  in  the  lower  third  of  the  arm. 


Fig.  24. — Emphysematous  gangrene.     Recoverj-  after  amputation  at  the 
shoulder-joint.     Episcopal  Hospital. 

Cellulitis.  —  Cellulitis  is  the  term  used  to  describe  inflammation 
of  the  subcutaneous  areolar  tissue.  This  tissue,  it  is  known,  consists 
essentially  of  lymph  spaces  lined  by  endothelial  or  connective  tissue 
cells;  and  it  is  now  generally  believed  that  these  spaces  have  no 
direct  communication  with  the  lymph  vascular  system.  Certainly 
cellulitis,  as  such,  is  clearly  distinguished  from  lymphangeitis  on  the 
one  hand,  and  from  infectious  dermatitis  on  the  other.  The  causes 
are  almost  without  exception  bacterial  infection,  streptococcic  rather 
than  staphylococcic,  usually  from  some  abrasion  or  lacerated  wound; 
but  occasionally  cellulitis,  extending  to  the  stage  of  suppuration, 
follows  a  confusion,  a  .sprain,  or  a  simple  fracture,  the  infection  in 


ERYSIPELAS 


67 


such  cases  hciii.u-  c()n\-c\<'(l  to  the  phicc  of  h'sscncd  resistance  through 
the  l)h)0(l-streain.  ("elhihtis  may  also  follow  extravasaticMi  of  urine, 
of  hlood,  etc. 

Symptoms. — Tiie    symptoms    are    those    of    inflammation,    widely 
dilfused  heneath  the  skin,  not  in  it,  and  characterized  esi)ccially  by 
swellini;-.     pitting    on    pressure,     and     the 
al)sencc  of  marked  redness  (Fig.  25). 

Treatment.  —  In  the  early  stages  rest 
procured  by  splints,  by  the  use  of  a  sling, 
by  elevation  of  the  part,  together  with 
local  anodyne  (lead  water  and  laudanum) 


Fiu.  25. — Suppurative  cellulitis  of  right  forearm, 
eleven  day.s'  duration.  From  infected  wound  of  wrist. 
Incised  and  drained  through  interosseous  membrane. 
Children's  Hospital. 


Fig.  20. — >Scar.^  from  multi- 
ple incisions  for  cellulitis  of 
calf.    Episcopal  Hospital. 


and  antiseptic  (corrosive  sublimate  and  alcohol)  applications,  may 
suffice  to  eflfect  a  cure.  As  soon  as  evidences  of  suppuration  occur, 
the  overlying  skin  should  be  incised,  in  as  many  places  as  may  be 
necessary,  to  give  exit  to  pus,  sloughs,  etc.  If  the  part  affected  is 
very  tense,  as  is  frequently  the  case  in  the  forearm  and  hand,  it 
is  advisable  to  make  free  longitudinal  incisions  even  before  pus  is 
formed,  as  the  relief  of  pressure  will  enable  the  body  tissues  to 
combat  the  infection  much  more  readily,  and  may  prevent  extensive 
sloughing.  Fig.  26  shows  the  scars  of  multiple  incisions  for  cellulitis 
of  the  leg. 

Erysipelas. — Erysipelas  (a  word  usually  supposed  to  be  derived 
from  two  Greek  words  signifying  red  skin),  known  formerly  as  St. 
Anthony's  Fire,  is  a  specific  inflammation  aft'ecting  the  skin,  the 
subcutaneous  tissues,  or  both.  Occasionally  the  mucous  or  serous 
membranes  are  involved.  It  is  a  specific  disease  clinically;  and 
according  to  some  authorities  its  cause,  the  Streptococcus  erysipelatis 


G8  DISEASES  RESULTING  FROM  INFLAMMATION 

(Fehleisen,  1884),  is  specific,  in  the  sense  that  it  causes  no  other 
disease;  but  equally  good  authorities  maintain  that  it  is  not  a 
specific  microbe,  but  merely  a  variety  of  the  common  streptococcus, 
which  for  some  unknown  reason  at  certain  times  does  not  produce 
the  usual  symptoms.  The  seat  of  the  inflammation  is  the  lymphatic 
spaces  of  the  skin  itself  (dermatitis)  and  of  the  subcutaneous  tissues 
(cellulitis.) 

Erysipelas  probably  always  is  due  to  the  presence  of  a  solution 
of  continuity  of  the  skin  or  mucous  membrane,  through  which  the 
bacteria  enter  the  tissues;  but  while  it  is  not  extremely  rare  in  patients 
with  lacerated  wounds  and  compound  fractures,  it  arises  much  more 
often  as  the  so-called  idiopathic  variety,  in  which  the  wound  probably 
is  some  insignificant  abrasion.  Especially  is  this  the  case  with  facial 
erysipelas,  one  of  the  most  prevalent  forms,  the  wound  of  entrance 
being  probably  some  excoriation  of  the  nasal  mucous  membrane. 
The  eruption  is  characterized  by  its  intense  redness,  which  returns 
immediately  on  the  removal  of  pressure;  by  its  glazed  or  shiny  surface; 
frequently  by  resicidation;  by  the  raised,  irregnlar,  and  well-defined 
borders  of  the  inflamed  area;  and  by  the  erratic  manner  in  which  it 
spreads  (Plate  I,  Fig.  2).  The  inflammation  is  always  most  intense 
at  the  periphery  of  the  patch,  while  the  centre  may  begin  to  fade 
away  very  quickly.  In  simple  erythema  the  patches  have  no  ten- 
dency to  spread,  their  edges  are  not  raised,  and  vesiculation  is 
unknown.  In  scarlatina  the  rash  is  not  localized,  it  is  neither 
well  defined  nor  are  its  margins  elevated  above  the  surrounding 
skin;  vesiculation  is  absent;  it  is  a  rare  disease  in  adults;  and  a 
history  of  contagion  may  be  obtainable.  The  dermatitis  resulting 
from  Rhits  Toxicodendron  is  very  difficult  to  distinguish  from  ery- 
sipelas, except  by  the  history;  the  same  is  true  of  saprophytic 
dermatitis  {erysipeloid  of  Rosenbach),  due  to  local  infection  from 
decaying  fish,  etc.  In  ordinary  cellulitis  the  redness  is  less,  and 
the  raised  margins  and  vesicles  of  erysipelas  are  absent;  and  as  the 
skin  itself  is  not  involved  in  cellulitis  the  disease  does  not  affect 
the  ears  nor  usually  the  skin  over  the  tip  of  the  nose,  in  which 
situations  subcutaneous  tissue  is  practically  absent.  In  erysipelas, 
on  the  other  hand,  the  pinna  of  the  ear  is  prone  to  invasion. 

Symptoms. — The  subjective  symptoms  are  marked:  these  are  pain, 
tingling,  and  a  feeling  of  tension  in  the  affected  parts,  which  are 
exquisitely  tender;  there  is  high  fever,  rapid  pulse,  furred  tongue, 
often  delirium,  and  occasionally  nausea,  vomiting,  and  chills.  As  a 
rule  there  are  no  prodromal  symptoms  of  importance.  The  eruption 
seldom  lasts  more  than  four  days  in  one  spot;  from  the  original  focus 
it  may  wander  irregularly  over  the  body,  or  may  break  out  in  an 
entirely  different  region.  As  the  inflammation  subsides,  the  skin 
becomes  brownish  in  hue,  the  vesicles  dry  in  the  form  of  scabs,  and 
the  part  appears  more  or  less  wrinkled.  In  facial  erysipelas  edema 
is   marked,  the   eyes  being  closed   and   the   nose   and   ears  swollen 


< 


TREATMENT  OF  ERVSIPELASi  69 

beyond  all  recoffiiition.  There  is  a  tendency  for  the  disease  to  spread 
to  the  scalp;  here  the  redness  is  less,  anil  the  general  <liaracteristics 
of  cellulitis  are  more  evident. 

Complications.  In  facial  erysi])elas  thiTC  is  always  a  danj^cr  of 
vttniiKjifis,  from  inxohcment  of  the  angular  \v'u\  or  one  of  the 
emissary  veins  of  the  skull.  Nephritis  may  result  from  the  strain 
put  upon  the  kidneys  in  the  elimination  of  toxins.  Endocarditis, 
yhurisy,  yncniuoma,  ijeritonitis,  arthritis,  and  general  seyticemia 
occasionally  are  o])served.  Phlrgnionovs  erysiyelas,  so-called,  is 
streptococcic  inflammation  of  the  cellular  tissues  accompanying 
erysipelas  of  the  skin.  If  the  erysipelatous  inflammation  invades 
the  fauces  (angina),  or  the  larynx,  producing  edema  of  the  glottis, 
laryngotomy  may  be  necessary. 

Prognosis.  —  Erysipelas  is  a  serious  disease,  though  seldom  the 
direct  cause  of  death.  S.  Erdman  (1913)  gives  the  hospital  mor- 
tality as  11  per  cent.  One  attack  seems  to  predispose  the  patient  to 
recurrence. 

Treatment. — When  occurring  in  a  hospital  ward,  cases  of  erysipelas 
should  be  isolated;  for  although  contagion  through  the  air  has  not 
been  known  to  occur,  the  infection  of  other  patients  by  contact 
cannot  always  be  prevented.  The  surgeon  who  dresses  the  wounds 
of  an  erysipelatous  patient  should  not  practice  obstetrics  while  so 
engaged.  O.  \Y.  Holmes  (1843)  long  ago  called  attention  to  the 
relation  between  erysipelas  and  puerperal  fever.  Constitutional 
treatment  is  to  be  given  only  as  indicated;  stimulants  and  tonics, 
especially  the  tincture  of  the  chloride  of  iron  or  quinin,  are  usually 
of  benefit;  a  purge  at  the  onset  of  the  attack  may  do  much  to  hasten 
its  disappearance.  In  the  way  of  local  treatment  very  little  can 
be  done  that  is  really  productive  of  any  marked  benefit.  Ichthyol 
ointment  has  been  much  used,  and  is  agreeable  to  the  patient.  A 
saturated  solution  of  magnesium  sulphate  is  claimed  by  some 
(Tucker,  1908)  to  have  almost  magical  power  in  dispelling  the 
eruption;  the  parts  affected  should  be  covered  with  gauze  wrung 
out  of  and  kept  constantly  wet  w4th  the  solution.  Apart  from  its 
well-known  local  anesthetic  action,  I  have  not  myself  observed  any 
marked  advantages  in  the  use  of  magnesium  sulphate.  Painting 
the  skin  with  collodion,  iodin,  or  strong  solutions  of  silver  nitrate 
(33  per  cent.),  about  an  inch  beyond  the  margin  of  the  erysipelatous 
patch,  has  in  some  cases  appeared  to  be  of  value  in  limiting  the  march 
of  the  infection;  but  when  it  is  remembered  that  the  dermatitis 
usually  subsides  of  itself  in  about  four  days,  it  is  seen  that  no  remedy 
can  be  said  to  be  specific.  When  the  subcutaneous  tissue  is  affected, 
the  treatment  is  the  same  as  for  cellulitis,  but  incisions  are  to  be 
emplo^-ed  even  earlier,  owing  to  the  greater  intensity  of  the  inflam- 
mation. Anti-streptococcus  serum  is  harmless,  and  if  possible  should 
be  administered  in  all  severe  cases.  Erdman  gave  vaccines  an  extended 
trial  and  concluded  that  they  were  useless. 


70 


DISEASES  RESULTINCj  FROM  INFLAMMATION 


GENERAL  AFFECTIONS  RESULTING  FROM  INFLAMMATION. 

In  addition  to  the  local  reaction  to  injury,  which  has  been  studied 
in  Chapter  I  under  the  heading  of  Inflammation,  there  is  also  a 
reaction  by  the  organism  as  a  whole.  In  even  the  simplest  cases 
the  local  reaction  is  accompanied  by  more  or  less  constitutional 
disturbance,  evidenced  chiefly  by  fever,  by  which  term  I  think,  with 
Adami,  it  is  convenient  to  designate  this  condition,  whether  or  not 
it  is  attended  by  elevation  of  temperature  {pyrexia).  Not  only  will 
many  aseptic  operations  be  followed  by  this  so-called  aseptic  fever 
(Genzmer  and  Volkmann,   1877),  but  some  patients  on  whom  no 

operation  has  been  done  (simple  fractures, 
etc.),  also  will  have  a  slight  rise  of  tem- 
perature and  other  signs  of  fever  on  the 
first  day  or  two  following  the  injury  (Fig. 
27).  In  most  cases  the  temperature  does 
not  exceed  100°  F.,  and  if  it  goes  beyond 
101°  F.  after  an  operation  it  is  very  prob- 
able that  infection  is  present.  Yet  in  one 
case  of  arthrodesis,  under  my  care  at  the 
Orthopedic  Hospital,  the  temperature  rose 
to  over  102°  F.  on  the  second  day,  but 
the  wounds  pursued  a  perfectly  aseptic 
course.  The  cause  of  the  aseptic  fever 
was  formerly  ascribed  to  the  liberation  of 
fibrin  ferment  in  the  circulation,  due  to 
thrombotic  changes  and  phagocytic  action 
at  the  seat  of  injury;  but  more  modern  investigations  tend  to  show 
that  it  is  due  to  the  liberation  of  nucleins  and  albumoses.  It  is  not 
impossible  that  the  cocci  normally  found  in  the  deeper  layers  of 
the  skin  may  be  at  fault,  and  that  the  fever  is  really  not  aseptic 
in  the  strict  sense  of  the  word.  No  special  treatment  is  required; 
the  symptoms  subside  spontaneously  in  a  day  or  so.  A  laxative 
usually  is  beneficial. 

Sepsis.^ — When  bacteria  or  their  products  enter  the  circulation, 
there  is  developed  the  condition  known  as  sepsis.  If  the  products 
of  pathogenic  bacteria  enter  the  circulation,  but  the  bacteria  them- 
selves remain  in  the  tissues  at  the  seat  of  primary  infection,  the 
condition  is  named  toxemia;  this  is  to  be  distinguished  from  intoxi- 
cation, the  condition  due  to  poisoning  by  non-bacterial  products 
(drugs,  products  of  perverted  metabolism,  etc.).  Diphtheria  and 
tetanus  are  typical  examples  of  toxemia.  If  the  bacteria  themselves 
are  present  in  the  circulating  blood,  the  condition  is  termed  bac- 
teriemia;  typhoid  fever  is  a  typical  bacteriemia,  the  bacilli  circulating 


Fig.  27. — Temperature  chart 
of  aseptic  fever ;  contusion  of  hip ; 
aged  sixty-four  years.  Episcopal 
Hospital. 


'  The  terminology  employed  by  writers  in  describing  the  conditions  named 
below  is  by  no  means  uniform.  I  have  adopted  the  designations  which  have 
seemed  to  me,  after  considerable  study,  to  be  most  characteristic  of  the  maladies 
named,  and  least  confusing  to  the  student. 


SEPTICEMIA  71 

l'rr('l\  in  the  blood,  and  producin<f  tlic  wcll-kiiow  ii  roscohir  ('ni])li()ii 
hy  lodifinjic  in  tlie  skin.  If  tlic  hattcriii  whicli  circulate  in  the  l)h)0(i 
are  hij^hly  pathoj^enic,  as  the  streptococcus  or  staphyhx-occus,  the 
condition  is  properly  denominated  septicemia;  hut  tiiis  term  is 
frequently  used  negligently  to  describe  any  form  of  sepsis  whatever. 
If  the  bacteria  circulating  in  the  blood  lodge  in  various  parts  of  the 
body,  forming  nniltiple  abscesses,  the  disease  is  named  pyemia. 
Under  the  name  sarco-sepsis,  Lockwood  (1896)  described  a  septic 
condition  due  to  the  presence  of  bacteria  in  the  tissues,  but  not  in 
the  circulating  blood;  but  as  it  is  impossible  to  distinguish  this  con- 
dition from  toxemia  or  septicemia  during  life,  and  as  it  is  doubtful 
whether  septic  symptoms  are  produced  })y  l)acteria  in  the  extra- 
vascular  tissues,  except  through  the  entrance  into  the  blood  of 
bacterial  toxins  (toxemia)  or  the  bacteria  themselves  (bacteriemia, 
septicemia),  it  seems  undesirable  to  complicate  the  study  of  sepsis 
by  discussing  this  condition  further.  Finally,  if  the  constitutional 
symptoms  are  due  to  absorption  of  products  of  saprophytic  (non- 
pathogenic) bacteria,  the  patient  is  said  to  be  suffering  from  sapremia. 

Toxemia. — This  is  the  condition  formerly  described  as  inflammatory, 
traumatic,  surgical,  sympathetic,  or  symjjtoinatic  fever.  As  modern 
methods  of  clinical  study  have  developed,  it  has  been  found  that 
this  condition  may  be  distinguished  from  aseptic  fever;  and  at  the 
present  day  it  is  usually  the  latter  that  is  meant,  when  reference  is 
made  to  inflammatory  or  surgical  fever.  For  the  development  of 
toxemia  it  is  necessary  for  bacteria  to  be  present,  and  they  are  rarely 
present  without  open  wound;  but  in  cases  of  intestinal  obstruction, 
and  in  infective  diseases  of  internal  organs  (appendicitis,  cholecys- 
titis, pyelitis)  it  is  the  rule  for  toxemia  to  exist.  If  no  focus  of 
infection  can  be  discovered,  the  sepsis  is  said  to  be  cryptogenetic. 
The  presence  in  the  blood  of  bacterial  toxins  causes  the  usual 
constitutional  symptoms  of  inflammation,  which  have  already  been 
detailed  (p.  31).  Traumatic  delirium  (p.  175)  is  probably  due  to 
toxemia.  If  the  aseptic  fever  customarily  seen  after  an  operation 
does  not  subside  in  two  or  three  days,  it  is  probable  that  some  septic 
focus  exists;  and  if  this  is  not  promptly  relieved  by  drainage,  the 
aseptic  fever  will  become  septic  in  nature,  and  the  patient  will  suffer 
from  toxemia,  the  commonest  form  of  sepsis. 

Treatment. — The  treatment  consists  in  removing  the  cause  of 
infection  when  this  is  possible,  and  in  thoroughly  draining  the  infected 
area  when  entire  removal  is  impossible  or  inexpedient.  Plenty  of 
water  should  be  introduced  into  the  system,  either  by  mouth,  or  by 
the  use  of  saline  solution  intravenously  or  by  hypodermoclysis  or 
proctoclysis.  If  the  toxemia  is  known  to  be  due  to  a  specific  cause 
(tetanus  bacillus,  colon  bacillus),  antitoxic  serum  should  be  adminis- 
tered; and  even  in  the  case  of  the  common  infections  (streptococcus, 
staphylococcus),  antitoxic  serum  occasionally  is  of  benefit. 

Septicemia. — Septicemia,  which  is  the  commonest  form  of 
bacteriemia   seen   by   surgeons,  is   distinguished  at   its   onset   from 


72 


DISEASES  RESULTING  FROM  INFLAMMATION 


toxemia  by  no  very  well  recognized  symptoms.  The  febrile  symptoms 
(pyrexia,  anorexia,  delirium,  etc.)  are  all  more  pronounced;  septic 
diarrhea  may  take  the  place  of  constii)ation,  and  intestinal  or  other 
internal  hemorrhages  may  occur  (Cf.  "critical  discharges,"  p.  31). 
Chilly  sensations  or  an  actual  chill  may  occur  early  in  the  disease, 
perhaps  due,  as  suggested  by  Adami  and  others,  to  relatively  high 
temperature  of  the  central  nervous  system.  The  temperature  usually 
is  not  very  high  (100°  to  102°  F.).  The  pulse  is  rapid  and  feeble, 
and  no  drugs  have  power  to  reduce  its  rate;  it  becomes  more  and 
more  rapid,  and  progressively  weaker  until  death,  which  is  the  usual 
termination  of  surgical  septicemia  (Fig.  28).  In  some  patients  who 
have  seemed  to  do  well  after  evacuation  of  septic  foci,  rapid  death 
occurs  from  so-called  terminal  infection  (Fig.  29).  Clinically  speak- 
ing,   it    is   usually    impossible   to   distinguish  between  toxemia  and 


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Fig.  28. — Puerperal  septicemia;  death. 
Episcopal  Hospital. 


Fig.  29. — Diffuse  purulent  peritonitis  from 
appendicitis.  Death  from  terminal  infec- 
tion (residual  abscess).     Episcopal  Hospital. 


septicemia,  except  that  the  latter  is  little  influenced  by  treatment. 
Sometimes  by  blood  cultures  it  is  possible  to  ascertain  the  presence 
of  bacteria  in  the  circulating  blood  during  life;  but  as  the  number 
present  in  the  blood  may  be  few,  a  sterile  culture  is  usually  no  proof 
that  bacteriemia  does  not  exist.  The  presence  of  staphylococcus 
albus  in  the  culture  usually  is  due  to  contamination  from  the  skin. 
Treatment.^ — Treatment  of  septicemia,  as  already  indicated,  usually 
is  impotent  to  stay  the  course  of  the  disease.  As  pointed  out  by 
Lockwood  (1896),  at  autopsy  the  bacteria  are  found  even  in  the 
coronary  arteries  of  the  heart,  and  the  persistent  rapidity  of  the 
pulse  may  thus  be  accounted  for.  Nevertheless,  as  the  diagnosis 
is  sometimes  impossible,  except  at  autopsy,  all  the  measures  sug- 
gested for  the  treatment  of  toxemia  should  be  employed  in  these 
cases,  and  it  is  possible  that,  in  some  patients,  life  may  be  saved. 


PYEMIA 


73 


Park  speaks  favorahly  of  the  use  of  rngnenUnn  Crede,  which  is 
absorbed  through  tlie  skin;  and  he  tliinks  benefit  is  derived  from 
"tlie  dissemination  througliout  the  system  of  the  antiseptic  virtues 
of  tlie  silver  itself."  He  also  connnends  the  intravenous  use  of  a 
solution  of  Crede's  soluble  silver  (1  gram  of  silver  in  1000  c.c.  of 
water).  Barrows  has  used  formalin  solution  (1  to  5000)  intra- 
venously with  alleged  benefit. 

Pyemia. — Nearly  invariably  this  is  associated  with  thrombosis  and 
embi)lism  (p.  237).  A  portion  (embuhis)  of  the  septic  clot  or  a  clump 
of  bacteria  from  the  original  focus  of  infection  becomes  detached, 
and  is  transported  in  the  blood  stream  to  the  nearest  set  of  capil- 
laries, where  it  lodges  (embolism).  Once  lodged,  the  bacteria  present 
in  the  embolus  produce  suppuration  in  the  new  location,  and  a 
secondary  or  metastatic  abscess  is  formed.     The  primary  thrombus 


Fig.  30. — Temperature  chart  in  pyemia;  acute  osteomyelitis  of  calcaneum; 
abscess  of  brain;  death.     Episcopal  Hospital. 


usually  is  venous  in  location,  and  the  detached  clot  naturally  might 
be  expected  to  be  arrested  in  the  pulmonary  circulation;  but  for 
some  reason  this  is  not  always  the  case,  the  embolus  passing  safely 
through  the  lungs  and  being  arrested  first  bj'  some  portion  of  the 
systemic  capillary  network.  Occasionally,  when  the  embolus  first 
is  carried  into  the  venous  current  it  travels  against  the  usual  course 
of  the  blood,  and  lodges  in  some  portion  of  the  venous  channels 
distal  to  the  primary  lesion.  This  process  is  known  as  retrograde 
embolism;  it  may  occur  in  suppurations  in  the  neighborhood  of  the 
vena  cava,  or  in  the  face,  the  blood  current  in  the  angular  artery 
flowing  sometimes  toward  the  brain  and  sometimes  outward.  If 
the  primary  lesion  is  in  the  distribution  of  the  portal  vein  {e.  g.,  the 
appendix),  the  first  set  of  capillaries  encountered  by  the  embolus 
will  be  the  hepatic,  and  multiple  liver  abscesses  will  result.     When 


74 


DISEASES  RESULTING  FROM  INFLAMMATION 


in  the  systemic  circulation,  many  different  regions  and  organs  may 
become  affected;  metastatic  abscesses  in  the  subcutaneous  tissues 
or  joints  are  most  easily  detected;  but  those  in  the  kidneys,  spleen, 
liver,  lungs,  or  brain  sometimes  may  be  diagnosed  during  life. 
The  original  focus  may  be  any  supjjurating  or  septic  lesion.  Burned 
surfaces  and  suppurative  lesions  of  bone  are  among  the  commonest 
causative  conditions. 

Symptoms. — The  symptoms  are  those  of  septicemia,  with  certain 
important  modifications.  The  temperature  is  typically  irregular"; 
its  variations  are  extreme,  and  the  absence  of  jjeriodicity  is  charac- 
teristic (Fig.  30).  The  highest  temperature  (104°  to  106°  F.  or  higher) 
on  one  day  may  be  at  a  certain  hour  in  the  afternoon,  whereas  the 
next  day  the  temperature  may  reach  its  highest  point  in  the  morning 
or  not  until  late  at  night;  or  hyperpyrexia  may  be  absent  for  an 
entire  day  or  so.  Chills  are  frequent,  immediately  preceding  the  fall 
of  temperature,  and  are  often  indicative  of  the  lodgement  of  an 
embolus,  which  may  be  attended  by  sudden  pain. 


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-Sapremia;  rapid  fall  of  temperature  after  evacuation  of  retained  secundines. 
Episcopal  Hospital. 


Prognosis. — The  prognosis  is  extremely  bad;  a  few  patients,  in 
whom  the  infection  seems  to  be  attenuated  and  the  course  of  the 
disease  chronic,  occasionally  recover.  The  staphylococcus  is  more 
frequently  the  causative  organism  than  the  streptococcus. 

Treatment. — Treatment  is  the  same  as  for  septicemia.  Constant 
vigilance  is  needed  to  detect  and  locate  metastatic  abscesses,  and 
they  should  be  drained  immediately,  when  accessible;  and  unless 
the  patient  is  so  ill  that  a  formal  operation  will  hasten  his  death, 
the  surgeon  should  not  hesitate  to  evacuate  abscesses  of  the  internal 
organs  or  even  the  brain.  By  ligating  or  excising  the  main  venous 
trunks  leading  from  the  original  lesion,  the  infection  sometimes 
may  be  successfully  localized  (internal  jugular  in  mastoiditis,  ovarian 
in  parametritis,  angular  in  facial  phlegmon,  etc.). 


SAPREMIA 


75 


Sapremia.  W'Iumi  dead  or  dying  tissue  is  in  contact  with  li\ing 
cells,  the  jjtoinains  and  other  ))oisons  elaborated  by  the  saprophytic 
bacteria  which  infest  the  former  may  be  absorbed  into  the  i)atient's 
body,  and  thus  produce  the  usual  syni])tonis  of  toxemia.  When 
healinji;  in  the  wounded  area  has  j)rogressed  to  the  stage  of  granu- 
lation, little  if  any  absorption  occurs;  but  injudicious  probing  of  a 
gramilating  wound  may  destroy  this  barrier,  and  evidences  of  sepsis 
will  follow.  It  is  sometimes  imjxjssible  to  distinguish  mild  grades 
of  sapremia  from  asei)tic  fever,  or  from  a  slight  toxemia  due  to 
absorption  of  the  products  of  pathogenic  bacteria;  but  usually  it  is 
easy  to  differentiate  clinically  between  sapremia  and  toxemia,  because 


2    3    4     5    *i    7    8    9   10  II  12  13  14  15  10  17   i%  1!)  20  21  22|23l24  25 


Fig.  32. — Tuberculosis  of  hip;  hectic  temperature  arrested  by  excision  of  hip. 
Orthopsedic  Hospital. 

in  the  former  case  there  always  is  some  dead  and  decaying  tissue 
present,  where  the  putrefactive  bacteria  multiply.  If  this  material 
is  removed,  the  bacteria  are  removed  with  it,  absorption  ceases, 
and  health  is  restored.  Sapremia  is  seen  in  its  typical  form  in  puer- 
peral cases,  absorption  occurring  from  the  retained  secundines  (Fig. 
31).  Hectic  fever,  which  is  classed  by  Park  as  chronic  sapremia,  is 
most  typical  in  patients  wdth  tuberculous  bone  disease,  where  siruises 
exist,  and  as  a  consequence  the  decaying  bone  has  become  infested 
with  saprophytic  bacteria.  Fig.  32,  from  a  patient  with  coxalgia 
under  my  care  at  the  Orthopedic  Hospital,  in  the  service  of  Dr. 
Harte,  shows  hectic  fever  promptly  arrested  by  excision  of  the  hip. 


CHAPTER    III. 

MODIFIED  FORMS  OF  INFLAMMATION  (SURGICAL 
INFECTIONS). 

Situated  pathologically  half  way  between  pure  inflammation 
and  neoplasms,  exists  a  group  of  surgical  diseases  usually  described 
as  the  infections  gramdornas.  This  term  implies  that  although  the 
lesions  are  definitely  known  to  be  caused  by  speciiic  microorganisms 
(which  is  not  the  case  with  tumors),  yet  the  tissue  reaction  to  these 
specific  irritants  is  characterized  rather  by  cell  accumulation  than  by 
actual  destruction  of  tissue  by  suppuration.  It  is  as  if  the  irritant 
were  too  timid  to  provoke  vigorous  resistance,  yet  too  enduring  to 
be  overcome  at  the  first  onslaught;  the  tissues  of  the  body  seem 
either  indifferent  to  the  invasion,  or  unable  to  continue  the  struggle 
with  the  success  which  usually  attends  their  warfare  in  acute  inflam- 
mation. While  the  more  important  of  these  modified  forms  of  inflam- 
mation (Tuberculosis,  Syphilis,  Actinomycosis)  partake  of  the  nature 
of  subacute  or  chronic  reactions,  there  are  others  (Anthrax,  Glanders, 
Tetanus,  Hydrophobia)  in  which  the  reaction  is  acute,  and  the  lesions 
less  circumscribed,  but  which  it  is  nevertheless  convenient  to  discuss 
in  the  same  chapter. 

CHRONIC  INFECTIOUS  SURGICAL  DISEASES. 

Tuberculosis. — Surgical  tuberculosis  includes  all  manifestations  of 
this  infection,  wherever  situated,  which  are  amenable  to  surgical 
treatment.  The  specific  cause  of  the  disease,  the  B.  tuberculosis 
(Koch,  1882),  gains  entrance  to  the  body  usually  through  the  digestive 
or  the  respiratory  tract.  It  has  been  held  by  good  authorities  that  the 
bacilli  may  pass  through  the  respiratory  or  intestinal  mucosa  and 
produce  no  lesions  in  it.  The  bacilli  lodge  most  frequently  in  the 
lung;  next  most  frequently  in  the  lymphatic  nodes — cervical,  bronchial, 
or  mesenteric.  Occasionally  infection  occurs  through  an  open  wound; 
inoculation  with  tuberculous  material  while  dissecting  produces  the 
so-called  anatomical  tubercle. 

The  bacillus  is  omnipresent  in  civilized  life,  and  it  is  by  no  means 
improbable  that  it  lives  as  a  parasite  in  the  bodies  of  most  apparently 
healthy  persons.  It  is  always  at  hand  to  attack  any  place  of  lessened 
resistance,  and  to  explain  its  prompt  appearance  in  such  locations 
it  is  usually  necessary  to  assume  that  it  was  present  previously,  though 
latent,  somewhere  in  the  patient's  body.  Scrofula,  formerly  con- 
sidered a  distinct  disease,  is  now  generally  recognized  as  identical 


SURGICAL  TUBERCULOSIS  11 

with  tuberculosis;  it  is,  liowover,  as  DaCosta  says,  a  useful  term  to 
describe  the  habit  of  body  of  such  as  are  easily  infected  with  tubercu- 
losis; in  other  words,  scrofula  may  be  considered  tuberculosis  in  its 
primary,  latent  state. 

Tuberculosis  is  most  often  i)rimary  in  the  lungs,  digestive  tract, 
lymph  nodes,  urinary  and  sexual  organs,  and  the  bones.  Surgical 
tuberculosis,  which  is  said  usually  to  be  secondary  to  an  inconspicuous 
lesion  of  the  lungs,  is  seen  especially  in  the  lymph  nodes,  the  bones 
and  joints,  the  sexual  organs,  peritoneum,  etc.^ 

Pathology. — The  local  lesion  produced  by  the  B.  tuberculosis  is 
called  a  iuhcrde;  its  proper  adjective  is  tnhercidous ;  and  it  should  be 
distinguished  from  a  tubercule,  a  term  which  describes  the  anatomical 
form  of  the  lesion  of  a  skin  eruption  which  is  called  tubercular,  but 
which  is  in  no  way  connected  with  tuberculosis.  When  the  B.  tuber- 
culosis begins  to  proliferate  in  the  tissues,  its  first  effect  is  to  exert 
chemotactic  action  upon  the  connective  tissue  and  endothelial  cells 
in  its  immediate  vicinity.  It  does  not  exert  positive  chemotaxis  upon 
the  leukocytes  circulating  in  the  blood,  and  leukopenia  not  leukocy- 
tosis is  the  rule;  but  the  number  of  circulating  lymphocytes  may  be 
relatively  increased.  Locally,  as  the  tissue  cells  accumulate,  their 
appearance  changes,  the  cells  swell  up,  become  pale,  and  resemble 
epithelial  cells  so  closely  that  they  are  widely  known  as  epithelioid 
cells.  This  accumulation  of  epithelioid  cells  around  the  tubercle 
bacilli  causes  an  anemia  of  the  central  area,  and  the  epithelioid  cells 
themselves  gradualh'  suffer  from  lack  of  nourishment,  and,  instead 
of  actively  dividing  and  multiplying  their  number  as  at  first,  they 
seem  to  be  unable  to  carry  the  process  of  reproduction  further  than 
the  stage  of  division  of  the  nuclei;  so  that  among  the  epithelioid  cells 
there  soon  appear  two,  three,  or  more  large  cells  with  multiple  nuclei, 
arranged  around  the  periphery  or  at  the  two  poles  of  the  cell— the 
so-called  giant  cells.  In  the  area  immediately  surrounding  the  giant 
cells  and  epithelioid  cells,  the  lymphocytes  accumulate;  while  the 
centre  of  the  tubercle  is  composed  of  tissue  and  cellular  debris  under- 
going caseous  degeneration,  which  is  the  form  of  anemic  necrosis 
particularly  characteristic  of  tuberculosis.  Some  phagocytosis  exists, 
but  it  sometimes  seems  as  if  the  tubercle  bacilli  continued  their  exist- 
ence as  parasites  even  within  the  cell  bodies  of  their  victim:  they  are 
most  apt  to  be  seen  within  the  giant  cells;  they  are  frequently  present 
in  the  epithelioid  cells;  but  are  said  never  to  be  found  within  the 
lymphocytes.  The  histological  tubercle,  thus,  maj'  be  represented 
diagrammatically  (Fig.  33)  as  composed  of  three  portions:  (1)  a  cen- 
tral caseous  or  necrotic  area,  in  which  may  be  a  giant  cell,  its  own 
centre  showing  commencing  caseation;  (2)  the  epithelioid  cells  sur- 
rounding the  caseous  centre,  and  (3)  the  peripheral  aggregation  of 
lymphocytes. 

*  Some  modern  investigators  believe  that  the  bovine  form  of  Tubercle  bacillus 
is  responsible  for  "surgical  tuberculosis,"  while  the  human  form  is  that  usually 
found  in  the  lungs. 


78 


CHRONIC  INFECTIOUS  SURGICAL  DISEASES 


The  products  of  the  tul)ercle  bacillus,  spoken  of  generically  as 
tuberculin,  are  not  very  well  understood;  it  seems  probable,  never- 
theless, that  caseation  is  induced  by  the  toxins  set  free  from  the 
bodies  of  the  bacilli  when  they  die,  but  that  the  irritant  action  of  the 
living  bacilli  is  only  sufficient  to  provoke  cell  accumulation  and  multi- 
plication. These  various  products  of  tubercle  ])acilli  usually  exist 
in  greater  or  less  amount  in  the  body  fluids  and  excretions  of  animals 
suffering  with  tuberculosis;  and,  when  injected  into  other  animals 
afflicted  with  tuberculosis,  the  tuberculin  contained  in  them  produces 
a  characteristic  reaction  which  may  be  used  for  the  purpose  of  diag- 
nosis- (p.  81). 


Fig.  33. — Section  through  a  tubercle.     Upon  the  margin  of  the  tubercle  lymphoid  cells 
may  be  seen;  in  the  centre  epithelioid  cells  and  a  giant  cell.     (Lexer-Bevan.) 


The  primary  tubercle  may  be  replaced  by  granulation  tissue  formed 
from  the  surrounding  connective  tissue  cells,  and  healing  may  occur 
in  a  manner  similar  to  that  of  simple  inflammation.  Or  the  "pyogenic 
membrane"  may  isolate  and  encapsulate  the  tubercle,  and  thus  the 
disease  may  be  arrested;  calcification  is  a  frequent  sequel.  On  the 
other  hand,  some  of  the  bacilli  may  escape  through  the  cordon  of 
epithelioid  cells  on  guard,  and,  settling  in  a  neighboring  portion  of 
the  tissues,  they  may  there  proceed  to  form  a  new  tubercle;  and  as 
many  more  tubercles  are  formed,  the  area  may  become  visible  to  the 
naked  eye,  and  the  centre  of  the  entire  mass  may  be  seen  as  a  caseous 
nodule  surrounded  by  comparatively  healthy  tissue  (Fig.  34).    Two 


S  VRCKW  L    T  [  BER( '  l' LOS  IS 


79 


processes  may  thus  be  initiated — either  productive  or  dejjenerativc; 
the  former  gives  rise  to  tiil)crculi>n.s  (fun (/on ft)  ij;ran illation  tissue,  fre- 
quently descril)ed  as  the  tuberculous  gumma  (Figs.  35  and  37),  because 


.V 


M 


^.>.^^...::^ 


Fig.  34. — Cross-section  of  tuberculous  testicle,  showing  areas  of  caseation.  Skin 
adherent.  One  sinus  has  been  divided  in  the  section.  From  a  patient  in  the  Episcopal 
Hospital. 

it  is  very  difficult  to  distinguish  it  histologically  from  the  gummas  of 
syphilis,  actinomycosis,  etc.;  whereas  the  degenerative  changes  result 
in  the  formation  of  a  cold  abscess,  so  named  to  distinguish  it  from  the 


Fig.  .35. — Tuberculous  gummas  of  leg,  in  a  baby,  aged  eight  months. 
Children's  Hospital. 


ordinary  abscess  of  inflammation,  which  is  characterized  })y  its  heat. 
Tuberculous  granulation  tissue  has  a  great  tendency  to  displace  all 
normal  tissues  with  which  it  comes  in  contact:  in  bones  it  causes  the 


80 


CHRONIC  INFECTIOUS  SURGICAL  DISEASES 


disappearance  of  the  normal  osseous  structure;  in  joints  it  grows  upon 
the  synovial  membranes,  producing  fibrous  ankylosis;  in  tendon 
sheaths  it  spreads  along  their  course,  gradually  invading  the  tendons 
and  in  time  causing  their  entire  disappearance.  The  degenerative 
changes,  which  by  the  process  of  coagulation  and  liquefaction  necrosis 
change  tuberculous  granulation  tissue  into  cold  abscesses,  are  probably 
due,  as  already  pointed  out,  to  excessive  destruction  of  tubercle 
bacilli  with  liberation  of  their  endotoxins,  and  to  the  action  of  fer- 
ments set  free  by  the  death  of  cellular  protoplasm.  When  the  cheesy 
pus  finds  an  exit  for  itself,  the  tuberculous  abscess  is  converted  into 
a  tuberculous  sinus,  or  if  the  walls  of  the  abscess  cavity  are  unable 
to  collapse,  as  in  bone,  and  often  in  the  lungs,  a  tuberculous  cavity 
remains.    As  the  tuberculous  sinus  heals,  it  becomes  converted  into  a 


^^^KtSitmSk-^^ 

^<rt   ^^H 

J 

1      ^ 

f    >-\ 

t-i 

Fig.  36. — Scrofulous  ulcers,  one  month  Fig.  37. — Tuberculous  dactylitis(tuber- 

duration.     Two  months    after  incomplete  culous    gummas   of    fingers).     Children's 

operation  for  recurrent  tuberculous  cervical  Hospital, 
adenitis.     Episcopal  Hospital. 

tuberculous  ulcer  (Fig.  36).  It  w^as  once  hoped  that  by  the  admin- 
istration of  tuberculin  to  tuberculous  patients  their  tuberculous  lesions 
could  be  disintegrated  and  caused  to  discharge;  but,  unfortunately, 
it  has  been  found  that  sudden  disintegration  of  tuberculous  foci  is 
more  apt  to  be  followed  by  acute  generalized  miliary  tuberculosis, 
which  may  be  succinctly  described  as  tuberculous  pyemia.  Any 
secondary  infection,  moreover,  of  a  tuberculous  focus,  is  prone  to 
aggravate  the  condition  by  weakening  the  protective  layer  of  epithe- 
lioid and  lymphoid  cells  which  surround  the  tuberculous  area.  The 
great  danger  when  any  cold  abscess  discharges  is  that  of  secondary 
(pyogenic)  infection.  As  Calot  says,  the  opening  of  a  cold  abscess 
is  the  opening  of  a  door  by  which  death  soon  enters. 

Diagnosis. — The  detection  of  the  tubercle  bacillus  in  the  lesions 
renders  the  diagnosis  certain;  but  in  the  vast  majority  of  cases  this 


SURGICAL   TUBERCULOSIS  81 

is  not  rociiiisite,  as  the  clinical  appearances  are  quite  sufficient  to 
justify  the  diagnosis  of  tuberculosis.  The  indolence  of  the  reaction, 
the  slow  course  of  the  disease;  the  characteristic  cheesy  material 
discharged  from  the  sinuses;  the  absence  of  leukocytosis  in  uncom- 
plicated cases;  and  the  general  ai)pearance  of  the  patient;  these  all, 
when  conibiiu'd  in  one  indi\idual,  make  the  actual  detection  of  the 
tubercle  bacillus  an  unnecessary  task  in  most  cases  of  external  tuber- 
culosis (bones,  joints,  lymph  nodes,  skin,  etc.).  In  tuberculosis  of 
certain  internal  organs,  especially  the  kidney,  it  is  highly  desirable 
to  detect  the  bacilli  in  the  excretions.  Another  aid  to  diagnosis  is 
the  titherculin  test  (p.  78) :  old  tuberculin^  is  that  generally  used, 
the  initial  dose  in  adults  being  one-tenth  of  a  milligramme  (0.0001 
gramme)  hypodermically;  this  rhay  be  increased  at  subsequent  injec- 
tions to  1  and  even  to  5  milligrammes.  The  hyi)odermic  use  of  tuber- 
culin gives  reasonably  accurate  results,  and  I  prefer  this  method  to  the 
conjunctival  test  of  Calmette,  or  to  the  inunction  of  jMoro's  tuberculin 
ointment.  The  cutaneous  reaction  of  v.  Pirquet  is  usually  to  be 
preferred  in  children  (under  twelve  years  of  age),  but  as  it  appears 
to  indicate  the  existence  of  latent  or  healed  tuberculosis  (very  rare 
in  children)  quite  as  readily  as  an  active  focus,  it  is  not  regarded  as 
so  accurate  as  the  hypodermic  test  for  adults.  The  hypodermic  test, 
unless  repeated,  causes  reaction  only  when  there  is  an  active  focus  in 
the  body;  but  it  does  not  necessarily  indicate  that  the  lesion  suspected 
is  tuberculous.  If,  however,  its  use  causes  an  exacerbation  of  symp- 
toms in  the  suspected  lesion  {focal  reaction)  there  can  be  very  little 
doubt  of  its  tuberculous  character.  After  the  hypodermic  injection 
has  been  given,  the  patient's  temperature  should  be  recorded  every 
two  hours  for  a  period  of  24  hours:  a  positive  reaction,  indicating  the 
presence  of  tuberculosis,  consists  in  an  abrupt  rise  of  temperature  to 
101°  or  102°  F.,  occurring  usually  about  the  twenty-second  hour.- 
Sometimes  a  chilly  sensation  is  experienced  as  the  temperature 
begins  to  rise.  If  the  first  injection  is  negative,  a  second  and  even 
a  third  may  be  given,  gradually  increasing  the  dose.  I  have 
never  seen  any  untoward  result.  The  reaction  is  positive  in  most 
cases  of  tuberculosis  not  in  advanced  stages;  it  is  usually  negative 
when  secondary  infection  is  present,  with  amyloid  changes  in  the 
viscera  and  a  hectic  temperature;  but  in  such  cases  the  diagnosis  is 
easy  enough  without  this  test.  Indeed  it  is  quite  useless  to  employ 
a  tuberculin  test  if  the  diagnosis  can  be  made  clinically.  In  v.  Pir- 
quet's  method  three  small  areas  on  the  arm  are  abraded,  and  into 

^  Old  tuberculin  is  a  filtrate  of  a  concentrated  glycerin  extract  of  tubercle  bacilli; 
it  is  possible  that  some  of  the  bacilh  may  not  be  excluded  by  the  filter;  to  obviate 
this  danger  Koch  has  prepared  two  new  tuberculins:  of  these  Tuberculin  Oberst 
(T.  O.)  is  the  supernatant  liquid  obtained  by  centrtfugalization  of  a  concentrated 
glycerin  extract  of  tubercle  bacilli;  the  sediment  which  forms,  containing  the  bacilli 
themselves,  is  ground  up  and  again  centrifugalized,  and  forms  Tuberculin  Rest 
(T.  R.).  T.  O.  resembles  old  tubercuhn,  and  may  be  used  instead  of  it  in  diagnosis; 
T.  R.  is  used  in  treatment. 

2  An  earlier  rise,  especially  within  a  few  hours  of  the  injection,  probably  is 
due  to  some  contamination. 
6 


82  CHRONIC  INFECTIOUS  SURGICAL  DISEASES 

one  or  two  of  these  the  tubercuUn  is  rubhed;  the  other  abrasions 
being  used  as  controls.  On  the  second  or  third  day,  in  tul)ercu- 
lous  cases,  the  infected  area  shows  a  characteristic,  erythematous, 
papular,  and  even  vesicular  eruption. 

Treatment. — Constitutional  and  hygienic  treatment  are  quite  as 
imi)ortant  in  surgical  as  in  medical  tuberculosis.  The  majority  of 
patients  with  surgical  tuberculosis  are  children  of  a  school-going 
age.  It  is  better  for  them  to  give  up  school  for  one  or  two  years, 
until  their  constitution  is  strong  enough  for  them  to  conquer  the  dis- 
ease, than  to  attempt  to  keep  up  in  their  classes  and  grow  physically 
worse  and  worse.  It  may  not  be  possible  for  them  to  sleep  in  the 
open  air,  but  they  can  at  least  sleep  with  all  the  windows  in  their 
room  open,  and  be  out  of  doors  as  much  as  possible  during  the  day. 
In  hospitals  provided  with  suitable  roof-gardens,  where  the  patients 
may  be  kept  in  the  open  air  practically  twenty-four  hours  out  of  the 
twenty-four,  it  has  been  found  that  operative  treatment  is  scarcely 
ever-required.  In  institutions  where  it  is  impossible  for  one  reason 
or  another  to  keep  the  bed-ridden  patients  out  of  doors  constantly, 
it  usually  is  quite  possible  for  their  beds  to  be  wheeled  out  of  doors 
and  left  out  from  7  a.m  to  7  p.m.  It  is  by  no  means  necessary  to  have 
a  hospital  in  the  country  for  these  patients:  porches  and  balconies, 
even  if  roof-gardens  cannot  be  obtained,  will  accomplish  the  same 
results  in  the  most  thickly  settled  parts  of  the  city.  Hand  in  hand 
with  the  open  air  treatment  must  go  full,  wholesome  diet,  especially 
milk  and  eggs;  and  the  only  medicine  usually  required  is  cod  liver 
oil,  which  seems  to  act  better  than  any  otiier  remedy  in  increasing 
the  appetite  and  causing  the  patients  to  put  on  flesh.  In  the  rare 
cases  where  it  does  not  do  good,  the  syrup  of  the  iodide  of  iron,  the 
compound  syrup  of  the  hypophosphites,  or  other  remedies,  may  be 
tried. 

Locally,  I  am  convinced  that  tuberculosis  of  the  soft  parts  demands 
a  different  treatment  from  that  of  bone.  In  the  latter  case  such  re- 
markable results  are  obtained  in  children  by  local  rest,  without  opera- 
tive interference,  that  I  am  extremely  conservative  in  urging  any 
other  surgical  treatment:  the  use  of  plaster  casts,  braces,  weight 
extension  in  bed,  together  with  proper  hygienic  treatment,  will  cure 
nearly  all  patients  in  whom  these  methods  are  adopted  early.  As 
regards  tuberculosis  of  the  soft  parts  (lymph  nodes,  generative  and 
urinary  organs,  peritoneum),  however,  local  rest  is  usually  impossible 
to  secure,  and  I  feel  sure  that  better  results  are  obtained  ])y  radical 
operation,  removing  the  entire  disease;  and  when  this  is  impossible, 
as  in  the  abdomen,  at  least  remoA'ing  the  primary  focus.  The  local 
treatment  adapted  to  each  form  of  tuberculosis  will  be  pointed  out 
when  the  surgery  of  those  portions  of  the  body  is  discussed. 

Syphilis. — This  is  an  infectious  granuloma  due  to  inoculation  with 
the  Treponema  pallidum  {Spiruchata  pallida),  a  parasite  described  by 
Schaudinn  and  Hoffman  (1905),  and  obtained  in  pure  culture  iii  1911 
by  Xoguchi  and  by  Hoffmann. 


PATHOLOGY  OF  SYPHILIS 


S3 


Pathology. — This  organism  usually  gains  access  to  the  tissues 
through  sonic  abrasion  or  excoriation  of  the  skin  or  mucous  mem- 
branes, being  inoculatecl  directly  from  a  sore  in  another  person  sull'cr- 
ing  from  syphilis  {'uiniicdiatc  cunfaffiun).  Occasionally  vicdiaic  con- 
tagion occurs,  the  virus  being  transmitted  by  means  of  soiled  towels, 
eating  and  drinking  utensils,  etc.  When  inoculated,  there  follows  a 
period  of  inruhaiion,  averaging  from  three  to  five  weeks,  during  which 
the  microbes  multii)ly  at  the  site  of  primary  in\asion,  and  are  carried 
by  the  lymi)h  channels  to  the  nearest  lymph  nodes;  so  that  by  the 
time  the  local  reaction  appears  at  the  site  of  original  inoculation,  the 
disease  is  already  diffused  in  the  patient's  body.  Neisser  found  the 
blood  contained  the  virus  as 
early  as  the  fifth  day  after 
inoculation.  The  local  reac- 
tion (chancre)  resembles  the 
tubercle  in  some  ways:  a  col- 
lection of  round  cells  occurs, 
and  there  may  be  a  few  giant 
cells  present;  but  the  chancre 
is  particularly  characterized 
by  the  great  proliferation  of 
the  endothelial  cells  lining  the 
capillaries.  By  proper  stain- 
ing methods  the  presence  of 
the  Treponema  pallidum  may 
be  demonstrated;  otherwise 
the  histological  picture  is  not 
regarded  as  conclusive,  though 
endothelial  proliferation  is 
always  suggestive  of  a  syi)hi- 
litic  lesion. 

The  chancre  is  situated  in  the  true  skin  (derma) ;  usually  when  first 
seen,  exfoliation  of  the  overlying  epidermis  has  occurred,  converting 
the  primary  lesion  into  a  superficial  erosion;  in  some  cases  the  local 
reaction  is  much  more  marked,  and  the  deep  or  Ilunterian  chancre 
develops.  Usually  very  soon  after  the  appearance  of  the  chancre, 
enlargement  of  the  regional  lymph  nodes  may  be  detected;  and  not 
infrequently  the  lymphatics  leading  to  these  nodes  are  palpably 
enlarged.  There  follows  the  second  period  of  incubation,  lasting  on  an 
average  about  six  weeks;  during  this  period  the  virus  of  the  disease 
is  spreading  past  the  first  group  of  lymph  nodes,  and  is  carried  by 
the  blood-stream  all  over  the  patient's  body.  Various  prodromal 
symptoms,  such  as  fever,  malaise,  headache,  vague  "rheumatic" 
pains,  etc.,  may  be  experienced  during  this  time.  As  in  typhoid  fever, 
the  infecting  organisms  lodge  first  in  the  cutaneous  capillaries,  and 
the  well  known  rashes  of  syphilis  (secondary  lesions,  syphiJodermas) 
are  produced;  at  the  same  time  the  lymph  nodes  all  over  the  body 
become  enlarged,  especially  the  posterior  cervical  and  epitrochlear 


Fig.  .38. — Treponema  pallidum  (SpirochiBta  pal- 
lida):    a,  red;  b,  white-blood  corpuscles. 


84  CHROXIC  IXFECTIOUS  SURGICAL  DISEASES 

groups.  The  lesions  of  this  secondary  period  are  not  confined  entirely 
to  the  skin;  the  mucous  membranes  usually  are  also  affected,  the 
eruption  appearing  in  modified  form  in  the  mouth,  the  fauces,  and  the 
vagina.  The  histological  picture  of  these  secondary  lesions  presents 
nothing  pathognomonic  of  syphilis;  but  the  proliferation  of  the  endo- 
thelial cells  lining  the  bloodvessels  is  usually  sufficient  at  least  to  sug- 
gest the  S3"philitic  nature  of  the  disease,  and  the  specific  organism 
usually  may  be  detected  by  smears  made  from  the  ulcerated  sores. 
Still  later,  more  or  less  typical  lesions  appear  in  the  deeper  structures 
and  in  the  internal  organs.  These,  which  are  known  as  gummas,  are 
characteristic  of  the  third  stage  of  syphilis;  they  consist  essentially 
of  an  aggregation  of  round  lymphoid  cells,  with  an  occasional  giant 
cell  at  the  periphery  of  the  lesion;  bloodvessels  are  less  conspicuous 
in  the  tertiary  than  in  the  secondary  lesions  of  sj'philis.  The  Tre- 
ponema pallidum  rarely  can  be  found  in  these  tertiary  lesions;  it  is 
practically  never  to  be  detected  in  those  with  pyogenic  infections. 
As  in  the  case  of  tuberculosis,  so  here,  there  is  a  marked  tendency  for 
the  centre  of  these  lesions  to  undergo  various  forms  of  degeneration, 
of  which  the  hyaline  and  fatty  are  the  most  usual.  Instead  of  the 
cheesy  pus  so  characteristic  of  tuberculous  suppuration,  the  product 
of  syphilitic  suppuration  is  known  as  gummatous  pus.  In  tertiary 
as  well  as  in  secondary  lesions,  there  is  a  marked  tendency  for  the 
disease  to  be  productive  at  the  periphery  of  the  lesions,  while  degenera- 
tion occurs  in  the  centre.  This  is  thought  to  account  for  the  charac- 
teristic serpiginous  form  of  some  of  the  later  skin  lesions  (Fig.  930). 
The  tertiary  lesions  of  syphilis  heal  by  granulation  and  cicatrization, 
with  resulting  deformity  from  contraction  of  the  scar-tissue.  The 
scars  are  typical,  both  on  surfaces  and  in  the  interior  of  organs — in 
the  former  situations  the  regular  outline,  circular  form,  and  depressed, 
shiny  base  of  the  cicatrix  are  nearly  pathognomonic  of  a  former 
syphilitic  lesion;  while  the  radiating,  star-like  cicatrices  in  the  internal 
organs  usually  may  be  recognized  at  a  glance.  Secondary  infection 
with  pyogenic  bacteria  is  a  frequent  occurrence  in  gummas;  this 
hastens  the  destructive  process  and  increases  the  subsequent  deformity. 

No  tissues  are  exempt  from  the  ravages  of  s^'philis.  The  favorite 
seats  for  the  secondary  lesions  are  the  skin,  mucous  membranes,  and 
iris.  In  tertiary  syphilis  the  periosteum,  bones,  and  joints;  deep  sub- 
cutaneous tissues;  palate  and  nasal  structures,  iris,  retina,  and  choroid; 
the  internal  and  generative  organs;  and  the  nervous  system;  are  those 
most  usually  affected. 

This  brief  sketch  of  the  pathology  of  syphilis  will  suflBce  for  the 
present  chapter.  The  clinical  aspects  of  the  disease,  as  well  as  the 
treatment,  will  be  discussed  in  Chapter  XXVI,  while  important 
syphilitic  lesions  of  the  various,  parts  and  systems  of  the  body  will 
be  described  in  chapters  devoted  to  regional  and  systemic  surgery. 

Actinomycosis. — The  cause  of  this  disease  commonly  is  known  as 
the  Ray  Fungus,  from  its  appearance  under  low  powers  of  the  micro- 
scope (Fig.  39);  but  scientists  differ  as  to  whether  it  shall  be  classed 


ACTINOMYCOSIS 


85 


Fig.    39. — Grains  of  actinomyces  from 
human  pus.      X  450.     (Marwedel.) 


with  the  moulds  (liyphomycctes)  or  with  bacteria  (schizomycetes). 
This  organism  is  found  growing  on  hay  and  .straw,  and  also  in  the 
ground,  whence  it  may  he  incorporated  in  growing  vegctal)lc  matter. 
It  was  first  observed  by  von  Langcnbcck  in  1S45,  in  the  pus  from  a 
patient  with  caries  of  the  vertebne.  Formerly,  instances  of  tiie  dis- 
ease were  considered  sarcomatous  or  carcinomatous  in  nature.  In 
cattle  the  ray  fungus  is  a  frequent  source  of  disease  (lumpy  jaw, 
swelled  head) ;  but  few  cases  have  been  obserxed  in  which  actual  trans- 
mission from  animal  to  man  has  occurred.  The  usual  source  of  infec- 
tion in  man  is  believed  to  be  chew- 
ing of  diseased  grain;  but  J.  H. 
Wright  (1905)  claims  that  the  ray 
fungus  is  quite  commonly  found 
in  healthy  mouths,  both  of  man 
ami  beast,  and  asserts  that  the 
action  of  the  cereal  is  merely  to 
prepare  a  locus  minoris  resistentioe 
where  the  fungus  can  develop. 

Pathology. — Like  the  other  in- 
fectious granulomas,  actinomycosis 
is  characterized  by  a  local  produc- 
tive reaction.  There  is  very  little 
tendency  to  necrosis;  but  in  man- 
kind secondary  infections   are  the 

rule,  and  hence  suppuration  is  much  more  frequent  than  in  the  lower 
animals.  The  cellular  infiltrate  surrounding  the  focus  of  disease 
consists  of  small  round  cells,  giant  and  epithelioid  cells;  conversion 
into  granulation  tissue  occurs,  and  this  tends  to  cicatrize.  The  dis- 
ease is  prone  to  extend  along  sinuous  and  branching  tracts,  suppura- 
tion occurring  in  the  centre,  while  the  sinuses  are  lined  with  the 
granulomatous  tissue.  In  the  pus  discharged  from  these  tracts, 
the  colonies  of  the  fungus  are  visible  to  the  naked  eye,  as  minute 
yellow  granules;  these  impart  to  the  fingers  a  gritty  sensation  due  to 
the  presence  of  calcareous  salts.  The  disease  is  chronic,  and  unless 
vital  parts  are  attacked,  life  may  l)e  prolonged  for  years.  Occasion- 
ally metastatic  foci  are  developed  through  the  blood-stream;  but 
the  disease  never  extends  by  the  lymphatics,  and  enlargement  of  the 
regional  lymph  nodes  usually  is  an  indication  of  secondary  infection 
(Frazier). 

Symptoms. — Four  distinct  varieties  of  human  actinomj'cosis  are 
recognized:  the  oral,  the  pulmonary,  the  abdominal,  and  the  cutaneous. 
The  origin  of  the  first  has  already  been  described;  from  the  tissues  of 
the  mouth  proper,  the  jaws,  the  cheeks,  the  neck,  and  even  the  skull 
and  brain  may  be  invaded.  The  pulmonary  form,  due  to  inhalation, 
usually  assumes  the  character  of  a  low  grade  basal  pneumonia;  pleural 
effusion  and  invasion  of  the  thoracic  parietes  are  frequent.  The 
spine  may  be  involved,  and  the  cold  abscesses  formed  may  closely 
simulate  those  of  tuberculosis.     Abdominal  actinomycosis,  especially 


86 


CHRONIC  INFECTIOUS  SURGICAL   DISEASES 


frequent  in  the  neighborliood  of  the  cecum,  is  of  the  hyperplastic 
type,  abscess  formation  and  intestinal  perforation  being  rare;  the  dis- 
ease tends  rather  to  produce  adhesions  to  the  parietal  peritoneum, 
and  to  invade  the  a})dominal  wall,  producing  there  the  characteristic 
lesions  seen  whenever  the  skin  is  invaded.  Cutaneous  actinomycosis  ' 
frequently  may  be  diagnosed  without  microscopical  examination  of 
the  pus;  the  sinuses,  with  the  involuted,  hypertrophied  skin;  the 
chronic  and  nearly  painless  course  of  the  disease;  the  typical  "board- 
like"  induration,  sharply  outlined;  and  perhaps  the  presence  of  hard 
cords  under  the  skin  running  from  the  main  lesions  out  in  various 
directions;  all  make  a  picture  which  is  not  readily  mistaken  for 
an^'thing  else. 

Diagnosis. — This  must  be  made  from  malignant  tvmors,  which  may 
be  closely  simulated  by  the  hyperplastic  form;  from  osteon/ i/elitis  and 

tubercniovs  lesions  of  bones  and  joints;  from 
inflamed  sebaceous  cysts  of  the  face  (Fig. 
40),  which,  as  pointed  out  by  Lexer,  some- 
times bear  a  striking  resemblance  to  actino- 
mycosis; and  from  gummatous  and  other 
syphilitic  lesions. 

Treatment. — If  complete  extirpation  is 
possible,  this  should  be  done;  but  in  most 
cases  the  surgeon  must  content  himself  with 
freely  opening  all  the  sinuses,  removing  the 
granulation  tissue  with  A'olkmann's  sharp 
spoon  (Fig.  451),  cauterizing  the  remaining 
tracts  w  ith  the  actual  cautery  or  some  chem- 
ical caustic  (chloride  of  zinc  10  per  cent.), 
and  packing  the  wounds  with  iodoform 
gauze.  Iodide  of  potassium  is  said  to  have 
a  remarkable  effect,  administered  in  large 
doses  for  two  or  three  weeks  at  a  time  and 
then  discontinued  for  one  week.  Bevan 
(1908)  has  used  cupric  sulphate  pills,  one 
quarter  of  a  grain,  thrice  daily,  with  marked 
benefit;  he  also  irrigates  the  wound  with  1  per  cent,  cupric  sulphate 
solution.  This  method  is  based  on  the  agricultural  treatment  of  the 
diseased  grain.  Out  of  door  life,  and  hygienic  measures,  as  for  tuber- 
culosis, are  of  almost  equal  importance  with  topical  remedies. 

Madura  Foot. — Madura  foot,  first  observed  in  Madura,  India,  in 
1712,  is  occasionally  seen  in  America.  It  is  due  to  a  fungus  closely 
resembling  the  actinomyces;  one  foot  only  is  involved  as  a  rule; 
very  occasionally  the  hand  is  affected.  A  painless  swelling  forms  on 
the  sole;  softening  and  suppuration  follow.  The  course  is  chronic. 
Fistulse  form,  heal,  and  again  break  open.  Finally  all  the  structures 
of  the  foot  are  invaded.    Amputation  is  the  best  treatment. 

Blastomycosis. — This  is  a  surgical  infection  whose  chief  lesions 
are  manifested  on  the  skin,  caused  by  organisms  of  undetermined 


Fig.  40. — Multiple  seba- 
ceous cysts  of  the  face  simu- 
lating actinomycosis.  Epis- 
copal Hospital. 


ANTIIh'AX  87 

l)i(>l()j;ic'al  position,  known  as  l)laston)yc('tos.  A  few  cases  of  systemic 
infection  have  also  heen  reported.  According  to  He\aii  (HKISj  "tlie 
cutaneous  lesions  have  l.een  mistaken  most  often  for  \  (Trucous  tulicr- 
culosis,  less  often  for  syphilis,  and  occasionally  for  epithelioma. 
Tuherculosis  is  the  disease  which  is  most  apt  to  he  confused  with 
systemic  blastomycosis."  The  diagnosis  is  best  made  by  micro- 
scopical examination  of  the  pus  from  the  cutaneous  lesions,  or  by 
excluding  the  existence  of  tuberculosis  by  the  usual  tests.  Bevan 
thinks  potassium  iodirle  is  the  most  valuable  remedial  measure;  he 
gives  as  much  as  OOO  grains  a  day,  well  diluted.  Cupric  sulphate  has 
also  been  used.  Hygienic  measures  are  important.  In  advanced 
cases  the  lesions  must  be  treated  surgically,  by  excision,  curettement, 
cauterization,  etc. 

Rhinoscleroma.— Uhinoscleroma,  a  chronic  infiltrating,  j)roductive 
infection  of  the  nasal  mucous  membrane  (rarely  of  the  pharynx, 
larynx,  and  hard  palate),  is  almost  unknown  in  this  country,  though 
common  in  Austria  and  southwestern  Russia.  It  is  possibly  due  to  a 
diplobacillus  (v.  Frisch,  1SS2).  It  is  highly  destructive,  invading  all 
surrounding  tissues,  and  clinically  resembling  other  infectious  granu- 
lomas. Excision  is  the  best  treatment;  when  this  is  impossible 
enough  of  the  growth  should  be  removed  to  facilitate  breathing. 

ACUTE  INFECTIOUS  SURGICAL  DISEASES. 

Anthrax. — This  disease,  due  to  infection  by  the  B.  anthracis 
(Davaine,  1873;  Koch,  1877),  is  common  in  sheep,  horses,  etc.,  and 
may  be  transmitted  to  man  directly,  or  through  contagion  from  wool, 
hides,  etc.  Invasion  occurs  through  abrasions  of  the  skin  or  mucous 
membrane;  or  through  the  respiratory  or  the  intestinal  tract.  The 
period  of  incubation  is  one  or  two  days.  The  local  reaction  consists 
in  a  cellular  and  serous  exudate,  producing  marked  edema,  with  a 
tendency  to  central  necrosis.  Eighty-five  per  cent,  of  cases  affect 
the  head,  face,  and  neck.  In  severe  cases  anthrax  bacilli  enter  the 
blood  current,  and  bacteriemia  results;  as  the  bacilli  are  too  large  to 
pass  through  capillaries  of  ordinary  size,  they  are  arrested  at  various 
places  and  produce  car))unculoid  lesions  in  these  new  situations. 

The  cntatieoiis  form  {Charbon;  malignant  pustule)  is  characterized 
by  the  formation  of  a  papule,  changing  into  a  vesicle,  surrounded  by 
an  edematous  area  (Figs.  42  and  43) ;  no  pus  is  discharged.  The  vesicle 
dries  up,  a  scab  forms,  central  necrosis  occurs,  the  black  central  core 
completing  the  typical  picture.  The  pain  ceases,  and  in  mild  cases  the 
slough  may  be  cast  off,  and  spontaneous  healing  occur.  In  severer 
cases,  lymphadenitis  and  angeioleucitis  develop,  toxemia  becomes 
profound,  and  death  may  ensue  in  a  few  days.  The  jjulnwnary  form 
{ivoolsorter  s  disease)  is  of  slight  surgical  importance;  SO  per  cent, 
of  patients  are  said  to  die  by  the  fifth  day.  The  intestinal  form  is 
characterized  first  by  symptoms  of  ptomain  poisoning;  then  by  hem- 
orrhages; and  finally  the  lodgement  of  the  bacilli  in  the  cutaneous 


88 


ACUTE  IXFECTFOI'S  SURGICAL   DISEASES 


capillaries  produces  a  widespread  carbunculoid  eruption  soon  followed 
by  death. 

Diagnosis. — Anthrax  is  to  be  distinguished  from  other  surgical 
infections  by  the  history  of  exposure  to  the  infecticni;  by  the  local 
edematous  reaction,  with  central  black  core;  by  the  absence  of  pain 


S<^' 


Fig.  4:1. — Anthrax  bacilli.  Spore  formation.  From  an  agar  culture  twentj--four 
hours  old.  About  the  margin  of  the  photograph  are  a  number  of  free  spores.  X  600. 
(Karg  and  Schmorl.) 


Fig.  42. — Aiiriiiax  ',i  face 
Episcopal  Hospital. 


Fig.  4.3. — Anthrax  of  face.    Black  slough 
in  centre  of  edematous  area. 


and  suppuration;  and  finally  by  detecting  the  bacilli  in  smears  made 
from  the  lesion. 

Prognosis. — ^The  mortality  has  \aried  from  25  to  33  per  cent,  in 
collected  cases  (Frazier,  1906);  but  by  appropriate  treatment  it  may 
be  reduced  to  6  per  cent. 


GLAXDERS  89 

Treatment. — Excision  should  be  done  wlicii  possiljlc,  iis  is  usually  tlu; 
case  wlii'n  an  (.'xtrcniity  is  allcctc<l.  Injections  of  pure  carlx^lic  acid 
around  tiie  lesion  (fi\e  drf)ps  in  each  puncture)  have  seemed  to  be 
heneficia!  in  some  cases.  I'ressure  on  the  pustule  is  to  he  avoided. 
Locally,  antiseptic  applications  are  indicated.  In  severe  cases  Bar- 
lacli  (  HIOS)  surrounds  the  lesion  })y  a  circle  of  punctures  made  hy  the 
actual  cautery;  he  has  treated  23  cases  with  no  deaths,  ^lost  im- 
portant of  all,  however,  appears  to  be  the  use  of  Selavo's  serum  (1897); 
in  many  cases  of  the  disease  (pulmonary  and  intestinal)  it  is  the 
only  remedy  available;  'M)  to  40  c.c,  in  di\idc(l  doses,  are  injected  at 
ditl'erent  points  in  the  abdominal  wall.  This  dose  may  be  repeated,  if 
necessary,  the  following  day.  In  severe  cases  intravenous  injection 
should  be  tried  (Liiwen,  1908).  By  these  means  the  mortality  has 
been  reduced  to  G  and  even  to  3  per  cent,  in  large  series  of  cases. 

Glanders  ( Farcy j,  due  to  the  B.  mallei  (Loffler  and  Schiitz,  1882), 
is  common  in  horses,  asses,  and  mules  (equinia);  sheep  and  goats 
are  also  afi'ected.     P^rom  these  lower  animals 
the  disease  is  sometimes  convened  to  man  by  .  \ 

the  spray  emitted  by  the  horse,  mule,  etc.,  ,  /  ^!^\>^^ 

in    sneezing,   or   by   means  of  the   purulent  '^    ^\\<.ll^ 

discharge  from  other  sources.     Occupation  in        \\    tf^^""      ^M 
stables    is    therefore    a  predisposing    cause.         |  *<  '^'^i*     i*^    J    "^ 
Invasion  occurs  by  inoculation  of  an  abrasion  '  v/'  *]};»     ** 

of  the  skin  (farcy);  or  of  the  nasal  or  buccal        \       S\,  *'  ..^'^  \ 
mucous    membrane    {glanders);    or    through  \    {>  '    /''j 

the  respiratory  or  digestive  tract.    The  result- 
ing infection   runs  an  acute  (very  rarely   a     gia^,ders^fi37ci?luf  mllleif 
chronic)  course.     The  local  lesion  somewhat     (Abbot.) 
resembles  a  tubercle;  the  regional  lymphatics 

are  afi'ected  early,  and  dissemination  through  the  blood-stream  is 
rapid.  The  lesions,  wherever  situated,  are  specially  characterized  by 
their  tendency  to  rapid  suppuration.  Along  the  lymphatics,  small 
harfl  nodules  (farcy  buds)  appear,  and  soon  suppurate.  In  the  lungs 
multiple  foci,  which  soon  suppurate,  are  produced.  A  diffuse  pustular 
eruption,  sometimes  mistaken  for  smallpox,  frequently  occurs  in  the 
skin  (Fig.  45j .  In  the  subcutaneous  tissues  and  muscles,  hard,  movable 
nodules  appear,  especially  in  the  biceps,  flexors  of  forearm,  rectus 
abdominis,  and  pectoral  muscles;  the  nodules  soon  suppurate.  Bones 
may  be  invaded,  and  by  implication  of  joints  pyarthrosis  may  occur. 

Symptoms. — The  period  of  inculcation  varies  from  three  to  seven 
days;  malaise  and  indefinite  typhoidal  symptoms  are  the  first  to 
appear.  In  glanders,  naso-pharyngeal  granulomas  are  the  earliest 
lesions,  with  ulcerations,  causing  sero-sanguineous  catarrh;  then  pneu- 
monic signs;  and  finally  the  cutaneous  rashes,  and  subcutaneous  and 
muscular  nodes.  Leukocytosis  usually  is  not  marked.  In  farcy, 
the  skin  affected  becomes  intensely  inflamed;  farcy  buds  appear 
along  the  lymphatics  and  soon  suppurate;  while  the  later  symptoms 
resemble  the  last  stages  of  glanders. 


90  ACUTE  INFECTIOUS  SURGICAL  DISEASES 

Diagnosis. — In  the  acute  cases  this  is  rarel}'  made  l)efore  death. 
The  patient's  occupation,  microscopical  examination  of  the  discharges, 
and  a  negative  Wi(hd  reaction,  are  factors  which  may  indicate  the 
nature  of  the  malady.  By  the  time  the  characteristic  nodes  ai)pear, 
the  patient  is  beyond  the  reach  of  treatment.  In  animals  the  disease 
may  be  detected  by  the  "mallein  test"  (similar  to  the  tuberculin  test, 
p.  81).  The  chronic  form  of  the  disease  resembles  the  late  stages  of 
syphilis. 


Fig.  45. — Pustular  eruption  in  human  glander.s.      (Dr.  Zeit's  case.) 

Prognosis. — The  disease  is  extremely  fatal  (85  to  90  per  cent,  of 
cases).     Death  occurs  in  from  one  to  three  weeks. 

Treatment. — Isolation  should  be  immediate,  as  the  disease  is  easily 
convej^ed  by  both  immediate  and  mediate  contagion.  If  an  extremity 
be  affected,  amputation  is  indicated.  Localized  lesions  elsewhere 
should  be  excised  when  possible;  at  least  they  should  be  opened  and 
treated  with  rigorous  antiseptic  methods.  Curettement  and  scrub- 
bing are  liable  to  disseminate  the  bacilli.  Hygienic  treatment  often 
is  all  that  is  available. 

Tetanus  (Lockjaw). — This  disease,  characterized  by  tonic  and  clonic 
convulsions,  and  especially  by  locking  of  the  jaws,  is  caused  by  the  B. 
tetani  (Fig.  46),  discovered  by  Nicolaier  in  1884,  and  obtained  in  pure 
culture  by  Kitasato  in  1889.  The  bacillus  is  anaerobic  and  is  found 
especially  in  garden  soil,  barnyards,  stables,  etc.  It  probably  normally 
infests  the  intestinal  tract  of  cattle,  and  is  re-deposited  with  their 
dung.  So  long  as  the  mucosa  of  their  gastro-intestinal  tract  is  intact, 
they  are  not  liable  to  infection  by  this  channel.  Horses  are  particu- 
larly susceptible.    Tetanus  appears  to  be  endemic  in  certain  localities. 


TETANUS 


91 


Fig.  40. 


bacilli,    showing    spore 
(Kitasato.) 


Inoculation  occurs  only  tlirou<i;li  a  wound.  (Vyptoficiictic  fl'ornicrly 
called  idiopathic)  tctaini.s  is  that  t'orni  in  which  the  wound  of  entrance 
cannot  be  discovered,  lia\iu<j;  hcen  insi<;iuficant  in  extent,  or  l)eing 
on  a  nuicous  surface.  Inoculation  is  favored  by  anaerobic  conditions 
of  the  wound.  Thus  punctured  wounds,  contused  and  lacerated 
wounds,  and  wounds  in  which 
foreign  l)odies  (earth,  machine 
oil,  splinters,  wadding,  etc.)  are 
present,  offer  favorable  condi- 
tions for  the  development  of 
tetanus.  A  mixed  infection, 
especially  with  saprophytic  bac- 
teria, is  favorable  because  these 
organisms,  ])eing  aerobic,  absorb 
all  available  oxygen,  and  provide 
anaerobic  conditions  for  the  teta- 
nus bacilli.  Tetanus  is  seen 
after  compound  fractures  and 
gunshot  wounds;  during  the 
puerperal  state,  when  inocula- 
tion occurs  by  the  genital  tract; 
in  the  newborn  (tetany s  nascen- 
tiiim)  from  infection  of  the  um- 
bilical cord;  and  not  infrequently  in  cases  of  extensive  burns.  Con- 
tagion may  spread  from  one  patient  to  another  by  the  medium  of 
instruments,  dressings,  etc.  Postoperative  tetanus  has  been  studied 
b}'  ]\Iatas  (1909),  who  suggests  that  it  is  due  to  germs  of  tetanus, 
latent  in  the  patient's  intestinal  tract,  ingested  with  uncooked  food, 
and  infecting  the  operative  wound  by  fecal  contact.  There  is  no 
good  evidence  that  it  is  due  to  the  use  of  infected  catgut. 

Pathology. — After  inoculation  there  is  an  incubation  period  aver- 
aging probably  about  nine  days,  but  which  may  vary  from  one  day  to 
eight  weeks  or  more;  yet  when  so  long  a  period  has  elapsed  it  is  not 
always  possible  to  exclude  a  more  recent  inoculation.  The  duration 
of  incubation  is  due  largely  to  the  distance  of  the  wound  from  the 
spinal  cord,  and  to  the  conditions  present  at  the  site  of  inoculation. 
Experimentally  the  bacilli  are  easily  destroyed  by  the  normal  tissues 
of  the  body;  but  if  these  structures  (phagocytes  and  bactericidal 
fluids)  are  engaged  in  combating  foreign  bodies  or  other  bacteria  as 
well,  then  the  tetanus  bacilli  begin  to  exert  their  influence  more 
promptly.  The  tetanus  bacilli  remain  in  the  primary  wound;  the 
disease  is  a  pure  toxemia;  extremely  rare  are  the  cases  where  the 
bacilli  are  found  in  the  blood,  lymph,  or  other  body  tissues.  The  local 
reaction  caused  by  the  bacilli  is  in  no  way  characteristic,  and  is  insig- 
nificant in  extent.  The  toxins  they  produce  are  alone  responsible  for 
the  symptoms  of  the  disease:  so  long  as  no  toxins  are  produced,  no 
evil  effects  are  observed  from  the  presence  of  the  bacilli  in  wounds; 
and  if  toxins  alone  are  introduced  they  produce  symptoms  identical 


92  ACUTE  INFECTIOUS  SURGICAL  DISEASES 

with  those  seen  when  tlie  bacilli  are  present  and  nuiltii)lyinfi;  in  the 
wound.  The  toxins  jjroduce  no  syini)toms  until  they  an;  transported 
to  the  spinal  cord;  and  they  reach  the  spinal  cord  only  by  travelling 
along  the  motor  nerves.  Toxins  are  absorbed  directly'  by  the  nerves 
of  the  wounded  part  and  are  transported  through  them  to  the  spinal 
cord;  if  the  nerve  is  divided  the  toxins  will  ascend  as  far  as  the  section 
but  not  beyond.  Toxins  also  enter  the  circulation,  but  cannot  reach 
the  central  nervous  system  except  when  carried  to  the  peripheral 
ends  of  motor  nerves  and  absorbed  by  them.  Toxin  absorbed  from 
the  circulation  through  short  nerves  reaches  the  cord  sooner  than  that 
absorbed  through  long  nerves.  This  explains  the  early  appearance 
of  muscle  cramp  in  the  face  muscles  and  those  of  the  spine,  which 
may  occur  before  cramps  in  the  wounded  extremity. 

In  the  anterior  horns  of  the  cord,  congestion,  exudation,  and  ecchy- 
mosis  are  frequently  observed;  but  the  changes  are  not  pathognomonic 
for  tetanus.  When  once  the  cord  is  invaded,  the  infection  spreads 
from  segment  to  segment,  and  the  sensory  portions  are  affected 
directly.  The  toxin  appears  to  enter  into  chemical  combination 
with  the  nerve  tissue.  Tonic  contraction  of  the  muscles  is  caused  by 
irritation  of  the  motor  tracts;  while  the  implication  of  the  sensory 
portions  of  the  cord  renders  it  so  exceedingly  susceptible  to  stimulus, 
that  clonic  convulsions  are  often  superadded  to  the  tonic  spasms. 
Our  knowledge  of  the  pathology  of  tetanus  is  due  chiefly  to  the  work 
of  ]\larie  and  Morax  (1902),  and  of  Meyer  and  Ransom  ('190.3). 


Fig.  47. — Opisthotonos  in  third  ria\-  of  tetanus;  death  six  hours  later  in  convulsions. 
Note  also  sardonic  grin.     Episcopal  Hospital. 

Symptoms. — \'ague  prodromal  symptoms  occasionally  are  noted. 
When  the  incubation  period  lasts  less  than  ten  days,. the  disease  is 
said  to  be  acute.  Sometimes  the  wound  seems  painful,  or  a  chill  may 
occur.  Usually  the  first  thing  noted  by  the  patient  is  a  stiffness  of  the 
jaws  {trismus)  or  a  painful  contraction  of  the  extensors  of  the  neck; 
occasionally  spasm  occurs  first  in  the  muscles  of  the  wounded  part. 
These  primary  symptoms  are  quickly  followed,  usually  in  a  few  hours, 
by  more  or  less  generalized  cramps,  the  extensors  almost  always  over- 
coming the  flexors.  Thus  the  feet  are  fully  extended,  the  head 
retracted,  and  the  back  arched,  so  that  the  entire  body  may  be 


TETANUS 


93 


supported  on  tlie  occiput  and  tlie  I'cet  {opisthotonos)  (Fi^.  47);  e////;ro.v- 
thotoiios  is  tlie  term  used  for  the  oi)posite  condition,  when  the  action 
of  the  flexors  })red()nnniitcs,  and  the  l)ody  is  bowed  forward;  plriiro- 
ihotonos,  in  which  lateral  de\iation  of  the  s])ine  is  the  chief  feature, 
is  extremely  rare.  These  tonic  spasms  are  more  or  less  continuous, 
full  relaxation  rarely  l)ein<;;  attained  at  any  time  during  the  course 
of  the  disease.  The  clonic  convulsions  are  superadded  to  the  tonic 
spasms,  and  hrin*:;  on  aji;ain  exaj^gerated  deji;rees  of  opisthotonos,  etc. 
Then  the  oi)isthotonos  relaxes,  and  until  aj;ain  excited  general  rigidity 
is  all  that  remains;  but  the  jaws  usually  are  persistently  shut,  the 
head  retracted,  and  the  back  arched.  The  spasms  are  exceedingly 
painful,  and  terribly  exhausting.  They  recur  without  regularity. 
They  are  easily  aroused  by  a  draught  of  air,  a  slamming  door,  jarring 
of  the  bedstead,  etc.,  as  the  spinal  cord  is  in  a  state  of  extreme  hyper- 
excitability.  Difficulty  in  swallowing 
is  not  marked,  when  once  food  has 
entered  the  mouth.  Bronchorrhea  is 
frequently  troublesome,  and  hypostatic 
or  inhalation  pneumonia  may  develop. 
The  muscles  of  the  tongue  are  not 
affected  and  sjx'cch  would  l)e  distinct  if 
the  jaws  could  be  opened.  Tonic  con- 
traction of  the  facial  muscles  produces 
the  so-called  sardonic  grin.  This  may 
persist  during  convalescence  (Fig.  48). 
Respiration  is  difficult  and  labored. 
Asphyxia  is  frequently  threatened  in 
the  tonic  convulsions.  Spasm  of  the 
diaphragm  causes  the  fearful  "girdle- 
pain."  The  abdominal  muscles  are 
"as  hard  as  a  board."  Retention  of 
urine  frequently  occurs,  and  consti- 
pation is  extreme.  The  recurring  con- 
vulsions deprive  the  patient  of  sleep; 
nourishment  can  he  administered  only 

with  the  greatest  difficulty;  the  mind  remains  clear  to  the  end,  and 
death  is  often  welcomed  by  the  patient  as  the  only  relief.  High  fever 
is  an  unfavorable  symptom;  at  death,  and  afterwards,  the  tempera- 
ture rises  rapidly. 

Chronic  Tetanus. — This  term  is  used  in  two  senses:  (1)  For  cases 
with  an  incubation  period  of  more  than  ten  days.  (2)  For  those  in 
which  the  patient  survives  more  than  fifteen  days.  In  either  instance 
the  symptoms  are  less  severe.  Occasionally  permanent  contractures, 
especially  of  the  jaws,  persist  after  recovery. 

Diagnosis. — This  must  be  based  on  the  suspected  wound  infection; 
on  the  early  occurrence  of  retraction  of  the  head  or  of  trismus;  on  the 
generalized  tonic  and  clonic  convulsions;  on  the  entire  absence  of 
delirium;  and  on  exclusion  of  all  other  diseases.    It  seldom  is  possible 


Viv,.  4S.  -  Kisus  saidoiiiciis,  \h'Y- 
sisdiif?  (luring  convalescence  fioin 
tetanus.  Ayed  seven  years;  iiicu- 
hation  t(!n  days.  From  a  i)atient 
in  the  University  Hospital  under 
the  care  of  the  late  Prof.  Ash- 
hurst. 


94  ACUTE  INFECTIOUS  SURGICAL  DISEASES 

to  recover  the  bacilli  from  the  point  of  inoculation,  but  injection  of 
the  patient's  blood  serum  or  cerebrospinal  fluid  into  one  of  the  lower 
animals  may  cause  tetanic  convulsions. 

Prognosis. — This  is  bad.  The  general  mortality  is  about  GO  per  cent. 
Anders'  figures  (1905)  showed  a  mortality  of  74  per  cent,  for  cases 
developing  in  less  than  ten  days;  and  of  8.5  per  cent,  for  those  which 
lasted  more  than  fifteen  days.  Jacobson's  statistics  (1906),  from  all 
the  cases  treated  in  various  hospitals  during  given  periods,  showed  a 
mortality  of  cS.3.1  per  cent,  for  acute  and  of  43.6  per  cent,  in  subacute 
cases.  The  longer  the  period  of  incubation,  and  the  longer  life  is  pre- 
served after  the  symptoms  develop,  the  greater  is  the  chance  or 
ultimate  recovery.  With  early  diagnosis  and  prompt  and  efficient 
treatment,  the  mortality  of  acute  cases  should  be  reduced  to  20  per 
cent,  or  lower  (Ashhurst  and  John,  1913). 

Treatment. — Prevention  is  better  than  cure.  Extreme  care  must 
be  exercised  in  dressing  wounds  which  seem  predisposed  to  the  devel- 
opment of  tetanus.  Septic  punctured  wounds  should  be  opened  and 
treated  with  the  most  scrupulous  antisepsis.  Remove  all  foreign 
bodies  and  sloughs.  Swab  the  wound  with  3  per  cent,  alcoholic 
solution  of  iodin,  rinse  with  hot  peroxide  of  hydrogen,  and  pack 
lightly  with  gauze  soaked  in  the  iodin  solution.  Lacerated  and  con- 
tused wounds  must  be  even  more  freely  drained  than  where  no  prob- 
ability of  tetanic  infection  exists.  Inject  1500  units  of  tetanus  anti- 
toxin into  the  tissues  around  the  wound,  or  into  any  nerves  exposed 
in  the  wound;  and  repeat  this  injection  at  the  end  of  eight  or  nine  days, 
since  by  this  time  the  antitoxin  first  injected  will  have  disappeared, 
but  toxins  may  not  yet  have  been  produced. 

When  the  disease  has  once  developed,  active  treatment  is  impera- 
tive. A  few  hours'  delay  in  recognizing  the  malady  and  in  instituting 
proper  relief,  may  render  cure  impossible.  Stiffness  of  the  jaws  is 
enough  in  a  suspicious  case  to  justify  the  use  of  heroic  measures. 
The  inexperienced  surgeon  frequently  is  thrown  off  his  guard  because 
the  patient's  mind  remains  so  calm  and  clear.  The  patient  should 
be  isolated  at  once  in  a  quiet,  cool,  darkened  room,  and  a  special  nurse 
should  be  placed  in  charge.  The  principles  of  treatment  are:  (1)  To 
remove  the  source  which  supplies  the  toxins  (/.  e.,  the  bacilli  still  in 
the  wound);  (2)  to  neutralize  toxins  already  formed;  (3)  to  depress 
the  functions  of  the  spinal  cord;  and  (4)  to  sustain  the  patient  by 
nourishment,  nursing,  etc. 

1.  The  first  indication  involves  care  of  the  wound,  which  is  the  same 
as  recommended  for  the  prevention  of  tetanus. 

2.  To  neutralize  the  toxins,  antitoxin  should  be  used.  This  is  supplied 
in  tubes  containing  1500  units  (5  c.c.)  and  3000  units  (10  c.c.)  each. 
It  is  evident  from  the  pathology  of  the  disease  that  it  is  quite  extrav- 
agant to  inject  it  hypodermically  or  even  intravenously.  The  only 
way  in  which  it  can  act  upon  the  toxins  ascending  from  the  wound  is 
when  it  is  injected  directly  into  the  motor  nerves  of  the  part  affected, 
as  first  emplo\ed  in  1902  by  Kiister  in  a  case  of  laboratory  infection. 


TETANUS  95 

When  tji\t'ii  li\  jHukTinically  it  is  al).S()rl)C(l  by  the  lymph  spaces, 
readies  tlie  veins,  i)asses  throujjh  the  heart  and  lunfi;s,  and  is  then 
(listril)ute(l  l)y  the  arteries  to  the  entire  Ixxly,  (»nl\'  a  lioniceojjathic 
(h)se  reaching  the  special  ner\'e  or  ner\es  along  which  the  toxins  are 
travelling  to  the  spinal  cord.  If  used  suhcutaneously  at  least  100, 00(3 
units  should  he  administered  in  the  first  twenty-four  hours.  It  has 
been  j)ointed  out  by  Ashhurst  and  John  (191.'))  that  antitoxin  injected 
into  the  subarachnoid  space  of  the  cord  i)r()bably  acts  directly  on 
the  nerve  roots,  and  such  immediate  and  fa^'orable  effects  from  the 
repeated  intraspinal  administration  of  antitoxin  have  been  reported, 
that  I  think  it  should  be  employed  in  every  case.  Anesthesia  is  not 
necessary,  though  often  desiral)le.  Chloroform  is  better  than  ether. 
The  hollow  needle  is  inserted  between  the  second  and  third  lumbar 
spines  (p.  157),  and  a  few  cubic  centimeters  of  the  subarachnoid  fluid 
are  drawn  off;  the  antitoxin  syringe  is  then  attached  to  the  needle, 
and  from  oOOO  to  10,000  units  are  slowly  injected.  If  the  site  of 
inoculation  is  on  the  upper  extremity  or  head,  the  foot  of  the  table 
maj'  be  raised,  to  allow  the  antitoxin  to  gravitate  toward  the  medulla. 
This  injection  may  be  repeated  every  day  or  two,  as  required;  it  is 
easier  than  intraneural  infiltration,  which  requires  anatomical  as  well 
as  surgical  knowleflge.  If  no  marked  improvement  follows  the  sub- 
arachnoid injection,  within  six  or  eight  hours,  the  main  nerve  or 
nerves  leading  from  the  site  of  infection  should  be  isolated  under 
chloroform  anesthesia,  and  as  much  antitoxin  as  possible  should  be 
injected  into  each  nerve,  by  various  punctures  into  its  substance. 
The  nerve  swells  up  so  quickly  that  no  large  amount  can  be  intro- 
duced; on  several  occasions  I  have  injected  1500  units  (5  c.c.)  into 
the  sciatic  nerve  all  at  one  dose.  It  is  not  true  that  the  pressure, 
rather  than  the  antitoxic  action,  blocks  further  absorption  of  the 
toxins,  since  intraneural  injections  of  saline  solution  are  without  effect. 
Antitoxin  seems  perfectly  harmless,  and  no  fear  need  be  entertained 
of  using  too  much.  The  incision  should  not  be  closed,  but  a  stout 
silk  or  linen  ligature,  looped  loosely  around  the  nerve,  should  be  left 
hanging  from  the  wound,  which  should  be  lightly  but  copiously 
dressed.  If  the  symptoms  persist,  the  patient  must  be  chloroformed 
again  the  next  day,  and  the  intraneural  injections  repeated.  Possible 
injury  to  the  nerves,  which  does  not  appear  to  have  been  reported, 
is  of  insignificant  consideration,  compared  to  the  preservation  of  life. 
The  nerves  to  be  so  treated  in  the  lower  extremity  should  be  exposed 
in  the  upper  thigh;  for  wounds  of  the  sole  of  the  foot,  the  sciatic  nerve, 
and  for  injuries  of  other  parts  of  the  lower  extremity,  the  anterior 
crural  and  obturator  as  well  as  the  sciatic  must  be  injected.  In  the 
upper  extremity  the  nerves  may  all  be  exposed  by  a  single  incision  in 
the  axilla;  or  the  brachial  plexus  above  the  clavicle  may  be  injected. 
For  wounds  of  the  trunk,  intraspinal  injection  is  the  best  available 
remedy;  this  is  also  the  case  in  wounds  of  the  face  and  head.  Intra- 
cerebral injections,  after  trephining  the  skull,  have  been  used,  but 
as  the  cerebrum  is  not  materially  affected  by  the  toxins  this  operation 


96  ACUTE  INFECTIOUS  SURGICAL   DISEASES 

probably  is  useless.  Rogers  (1905)  has  used  intramedullary  injections 
with  success,  in  desperate  cases:  he  introduced  the  needle  in  the 
cervical,  upper  dorsal,  or  lumbar  region,  and  poked  around  until 
jerking  of  the  limbs  indicated  that  he  was  scratching  the  cord 
itself. 

3.  To  depress  the  functions  of  the  spinal  cord  drugs  may  be  given 
by  mouth  if  the  patient  can  swallow,  or  by  the  rectum;  hypodermic 
administration  is  best  when  possible.  These  drugs  should  be  admin- 
istered in  doses  sufficient  to  produce  some  effect;  10  to  20  grains 
of  chloral  hydrate,  and  twice  as  much  bromide  of  potassium,  may 
be  given  as  often  as  every  three  hours;  more  should  be  given  if  the 
patient  requires  it,  and  less  if  it  proves  to  be  sufficient  to  relieve 
the  pain  and  diminish  the  rigidit3\  ^lorphin  is  of  very  little  value. 
Chloretone  has  given  gratifying  results  (Hutchings,  1909).  It  is 
administered  by  mouth  or  rectum  in  doses  of  from  30  to  60  grains, 
dissolved  in  whisky  or  hot  olive  oil. 

Treatment  by  intraspinal  injections  of  magnesium  sulphate,  intro- 
duced by  Blake  of  New  York  in  1906,  is  based  on  the  anesthetic  effect 
of  this  drug,  when  injected  into  the  subarachnoid  space  (Meltzer, 
1905).  It  acts  as  a  spinal  depressant,  and  should  not  be  used  as  a  sub- 
stitute for  antitoxin.  Solutions  of  12.5  to  25  per  cent,  strength  are 
employed,  and  1  or  2  drachms  (5  to  10  c.c.)  are  used  at  each 
injection  (1  c.c.  for  every  25  pounds  of  body  weight).  It  is  a  dangerous 
remedy,  and  several  deaths  have  been  reported  following  its  employ- 
ment. 

Carbolic  acid  injections,  introduced  by  Bacelli  (18SS),  are  supposed 
by  some  to  have  a  specific  action  in  tetanus.  Subcutaneous  injec- 
tions of  Y  P^r  cent,  watery  solution  are  administered,  every  one 
or  two  hours,  preferably  along  the  spine,  until  80  or  100  eg.  are 
given  in  twenty -four  hours,  watching  for  constitutional  symptoms 
of  carbolic  acid  poisoning.  Experimental  evidence  (Camus,  1912) 
shows  this  treatment  to  be  useless,  but  clinically  some  good  results 
are  reported. 

4.  The  nursing  of  the  patient  is  very  important.  Clear  the  bowels  by 
a  brisk  purge  early  in  the  disease;  watch  for  retention  of  urine;  guard 
against  bed-sores.  Enforce  feeding,  by  the  stomach  tube  passed  under 
a  general  anesthetic  if  necessary. 

Hydrophobia  (Rabies,  Lyssa). — ^This  disease,  whose  exact  cause 
is  unknown,  is  characterized  by  clonic  spasms,  especially  of  the  faucial 
and  respiratory  muscles;  it  results  from  inoculation  with  the  virus 
contained  in  the  saliva  of  rabid  animals,  notably  dogs,  wolves,  cats 
(also  in  foxes,  sheep,  goats,  pigs,  skunks,  deer,  etc.).  Any  mammalian 
may  be  affected.  It  is  disputed  that  it  is  ever  conveyed  from  man  to 
man.  Though  infection  occurs  in  the  vast  majority  of  cases  by  bites, 
it  may  also  occur  through  scratches  by  claws  infected  with  saliva,  or 
by  an  animal  licking  an  existing  wound.  Wolf  bites  are  most  dan- 
gerous, because  it  is  said  the  hands  and  face,  unprotected  by  clothing, 
are  usually  bitten;  and  because  the  sharper  teeth  more  readily  pene- 


UYDUOl'llOBlA  97 

tnite  protoctod  parts.     It  is  possible  that  tlu;  \iriis  may  ))e  partly 
wiped  oil"  the  teeth  of  animals  hy  i)assiii<^  tliroii<;h  clothiiij^. 

The  disease  is  found  in  do<;s  in  two  forms,  the  J'lirioiis  and  the 
paralytic.  In  the  former,  the  dof^  is  at  first  sullen,  retiring  to  his 
kennel,  antl  looking  askance  at  every  one;  after  several  hours  he 
becomes  exceedingly  fidgety,  continually  shifting  his  posture;  suddenly 
he  becomes  irritable,  with  a  snai)i)ing  bark,  an  unsteady  and  staggering 
gait;  the  tongue  lolls  from  his  mouth,  swollen  and  red;  the  saliva  is 
profuse  and  viscid;  there  is  loss  of  appetite  and  presence  of  thirst. 
Later,  paralysis  of  the  extremities  occurs,  breathing  and  deglutition 
become  spasmodic,  and  convulsions  bring  on  death.  In  the  j)aralytic 
form,  the  disease  passes  at  once  from  the  sullen  to  the  i)aralytic  stage; 
the  dog  is  shy  and  melancholic;  there  is  no  disposition  to  bite;  he  is 
haggard  and  suspicious;  has  no  fear  of  water,  l)ut  docs  not  drink;  the 
tongue  lolls,  the  salixa  dribl)les,  breathing  is  difficult  and  laborious; 
and  tremors,  vomiting,  and  convulsions  precede  death  (Youatt; 
quoted  by  Forbes,  1888). 

Pathology. — The  virus,  entering  the  wound  with  the  saliva,  and 
probably  deri^-ed  from  the  salivary  glands,  is  absorbed  by  the  nerves 
of  the  bitten  part  (Di  Vestea  and  Zagari,  1887),  and  travels  by  them 
to  the  spinal  cord;  whether  some  toxin  alone,  or  the  infective  agent 
itself  is  thus  transmitted,  is  still  unknown.  Some  of  the  virus  may 
travel  through  the  neural  lymphatics.  The  virus,  after  reaching  the 
cord,  travels  up  it  to  the  medulla,  cerebellum,  and  cerebrum;  it  also 
travels  out  along  the  spinal  and  cranial  nerves,  and  in  this  way  reaches 
the  salivary  glands  of  the  patient,  especially  the  submaxillary  and 
sublingual;  the  saliva  becomes  highly  infectious.  After  death  there 
are  found  in  the  cerebrum,  cerebellum,  medulla,  and  cord,  and  also 
in  the  salivary  glands,  various  degenerati\'e  changes,  especially  marked 
in  that  part  of  the  cord  which  receives  the  nerves  of  the  bitten  part. 
The  most  important  microscopic  changes  are  in  certain  of  the  per- 
ipheral ganglia  and  in  the  hippocampal  convolution.  Van  Gehuchten 
and  Nelis  in  1900  found  changes,  seen  best  in  the  ganglia  of  the  vagus 
and  sympathetic  nerves,  consisting  in  proliferation  of  the  endothelial 
cells  lining  the  capsule  of  the  ganglion,  and  filling  up  the  spaces  between 
the  capsule  and  the  proper  cells  of  the  ganglion.  Negri  (1903)  found 
in  the  pyramidal  cells  of  the  cornn  Ammonis,  and  in  Purkinje's  cells 
in  the  cerebellum,  certain  cell  inclusions  which  he  regarded  as  para- 
sites and  the  cause  of  the  disease.  Nearly  all  observers  admit  that 
these  ganglionar  changes  and  the  presence  of  Negri  bodies  are  pathog- 
nomonic of  rabies;  they  are  found  in  other  diseases  only  with  the 
greatest  rarity;  but  many  dispute  Negri's  claim  that  the  bodies 
described  by  him  are  parasites,  and  deny  that  they  are  the  cause  of 
the  disease.  liambaud  (1907)  points  out  that  their  distribution  is 
not  what  would  be  expected  of  the  specific  cause  of  rabies;  that  the 
virus  passes  through  filters  which  arrest  the  Negri  bodies  (Park 
thinks  this  not  a  valid  objection) ;  and  that  protozoa  survive  tempera- 
tures (45°  C.)  which  readily  render  the  rabic  virus  inert. 
7 


98  ACUTE  INFECTIOUS  SURGICAL  DISEASES 

Symptoms. — After  inoculation,  there  is  a  period  of  incubation, 
varying  from  four  or  five  days  up  to  several  months  or  a  year.  The 
average  period  in  man  is  forty  days  (Ravenel,  1901).  Incubation  is 
shortest  following  bites  of  the  face  and  other  exposed  parts,  also  fol- 
lowing wolf  bites.  The  original  wound  usually  has  firmly  healed  long' 
before  any  symptoms  arise.  The  course  of  the  disease  was  described 
by  Virchow  as  embracing  three  stages:  (1)  The  first  stage,  which  may 
be  absent,  but  which  usually  lasts  from  a  few  to  twenty-four  hours. 
There  is  malaise,  lassitude,  headache,  twitching  of  the  throat,  stiff- 
ness of  the  neck,  a  feeling  of  suffocation,  and  rarely  slight  delirium. 
There  is  seldom  any  abnormal  sensation  in  the  wound.  During  this 
stage  the  virus  probably  is  ascending  the  cord.  (2)  The  second 
stage  is  evidenced  by  increasing  stiffness  and  pain  in  the  tongue, 
throat,  and  jaw  muscles;  there  is  dysphagia,  dryness,  and  great 
thirst;  profuse  salivation,  the  saliva  being  exceedingly  tenacious  and 
viscid;  this  necessitates  repeated  hmcking  which  has  been  fancifully 
likened  to  the  bark  of  a  dog.  Violent  spitting  is  exceedingly  charac- 
teristic. The  patient  is  fearful  of  infecting  those  about  him.  Speech 
is  difficult,  being  often  choked  off  by  gasps  and  sobs  due  to  pharyngeal 
and  laryngeal  spasm.  Swallowing  becomes  impossil^le,  the  sight  of 
food  or  liquids,  and  sometimes  the  very  sound  of  running  water, 
bringing  on  renewed  paroxysms.  The  special  senses  become  pre- 
ternaturally  acute;  according  to  Rambaud,  the  slightest  draught 
of  air,  as  breathing  gently  on  the  patient,  always  produces  faucial 
spasm.  General  convulsions  ensue;  there  is  high  temperature,  rapid 
pulse,  and  polynuclear  leukocytosis.  The  urine  is  deficient;  it  may 
contain  albumin  or  sugar.  The  mind  seems  in  terrific  dread,  in 
unutterable  despair,  or  furious  anger.  Insane  impulses  and  delusions 
are  not  uncommon;  the  staring  eye,  tensely  drawn  mouth,  with 
bloody  foam  on  the  lips,  and  haggard  countenance  precede  mania, 
which  closes  the  second  stage.  The  entire  duration  of  this  frightful 
scene  may  be  twenty-four  to  forty-eight  hours;  and  death  from 
asphyxia  in  a  convulsion  is  frequent.  (3)  The  third,  or  paralytic  stage 
is  evidenced  by  exhaustion  succeeding  to  mania  and  convulsions: 
saliva  dribbles  from  the  hanging  mouth,  the  tongue  lolls,  and  a  horrible 
gurgling  in  the  throat  portends  dissolution  (Forbes,  1881).  The  entire 
course  of  the  disease  may  be  run  in  sixteen  hours,  or  it  may  last  four 
or  five  days;  seldom  longer.  In  rare  cases  the  furious  stage  is  entirely 
absent,  the  disease  resembling  the  paralytic  type  seen  in  dogs. 

Diagnosis. — This  affection,  which  is  exceedingly  rare,  is  distin- 
guished from  pseudo-rabies  (hysteria),  by  the  history  of  a  bite  from 
a  truly  rabid  animal;^  by  the  period  of  incubation,  which  is  never  less 

^  To  determine  whether  or  not  the  animal  is  rabid,  it  should  not  be  killed 
immediately,  but  should  be  kept  under  observation  for  several  days,  or  at  least 
until  the  clinical  signs  are  noted  by  a  competent  veterinarian.  If  such  is  not  avail- 
able, the  dog's  head  should  be  cut  off  with  an  aseptic  knife,  and  sent  to  a  competent 
veterinarian  or  pathologist,  who  will  determine  from  the  microscopical  appear- 
ances of  the  plexiform  ganglion  and  cerebrum,  whether  or  not  the  animal  was 
afflicted  with  rabies.  This  fact  may  also  be  determined  by  inoculations  into  other 
animals,  but  this  method  may  take  several  weeks. 


IlYDIiOrUOBIA  99 

than  four  days;  and  by  the  ahnost  invarial)ly  fatal  termination  within 
ten  (lays.  In  liysteria  the  symptoms  are  often  immediate,  the  harking 
and  hydrophobia  are  absurdly  exaggerated,  the  dog  is  not  mad,  and 
death  does  not  occur.  Tetanus  is  due  to  a  wound,  not  a  bite;  there 
is  no  excitement,  fury  or  mania;  the  convulsions  are  tonic  more  than 
clonic;  the  jaws  are  firmly  shut  and  cannot  be  opened;  there  is  no 
spasm  of  the  tongue  and  fauces.  Tetanus  is  a  quiet  disease;  apart 
from  gritting  of  the  teeth  during  convulsions,  the  patient  makes  no 
noise.    Ivabies  is  a  furious  and  noisy  disease. 

Prognosis. — It  is  now  said  that  from  10  to  15  per  cent,  of  those  bitten 
by  rabid  animals  are  liable  to  develop  the  disease;  it  was  formerly 
claimed  by  Pasteur  and  his  followers  that  the  incidence  was  much 
higher,  even  as  much  as  75  per  cent.  Not  only  is  it  an  unusual  disease 
in  man,  but  it  is  by  no  means  common  in  dogs  and  other  animals. 
It  is  most  frequent  in  France,  Germany,  and  Russia;  it  is  very  infre- 
quent in  Great  Britain  where  there  are  extremely  stringent  quaran- 
tine laws  against  the  inij)ortation  of  dogs;  and  almost  unknown  in 
Norway  and  Australia.  Most  surgeons  never  see  a  single  case.  I 
never  saw  one.  Our  entire  knowledge  of  the  disease  is  due  largely  to 
veterinarians  and  to  directors  of  Pasteur  Institutes.  The  disease 
when  it  really  does  occur  is  frightfully  fatal.  There  are  a  very  few 
well  authenticated  cases  of  recovery,  accepted  as  such  by  competent 
critics. 

Treatment. — This  must  be  both  preventive  and  curative.  The  former 
includes  police  regulation  of  dogs  and  other  domestic  animals,  as  well  as 
ordinary  surgical  treatment  for  a  poisoned  wound,  and,  if  the  patient 
wishes,  the  so-called  Pasteur  treatment  by  preventive  inoculation.  As 
soon  as  the  wound  is  received,  constriction  should  be  applied  on  its  proxi- 
mal side,  to  prevent  possible  absorption ;  and  a  cupping  glass  should  be 
applied  to  suck  out  as  much  of  the  virus  as  possible.  In  emergency, 
the  patient  should  suck  the  wound  with  his  own  mouth,  spitting  out 
the  blood  thus  extracted.  The  best  antiseptic,  according  to  Rambaud, 
is  corrosive  sublimate  (1  to  1000);  the  compound  tincture  of  iodin  is 
also  good;  lemon  juice,  which  is  an  excellent  antidote  experimentally, 
may  be  used  in  emergency.  Caustics  are  worthless,  unless  heat  is 
used ;  and  when  available  antiseptics  are  better  than  heat. 

The  Pasteur  treatment  is  based  on  the  theory  that,  even  during  the 
period  of  incubation,  inoculation  with  extremely  attenuated  virus, 
whose  strength  is  gradually  increased,  will  be  sufficient  to  immunize 
the  patient  against  the  disease.  The  attenuated  virus  is  obtained 
from  the  spinal  cords  of  rabbits  dead  of  hydrophobia;  the  quantity 
(not  the  quality)  of  the  virus  in  the  cords  gradually  diminishes  in 
dry  air.  The  first  inoculation  is  made  with  an  emulsion  of  a  cord 
from  a  rabbit  dead  twelve  to  fourteen  days,  and  the  course  of  treat- 
ment extends  over  about  two  weeks.  There  is  no  doubt  that  in  the 
vast  majority  of  cases  inoculation  of  healthy  animals  according  to 
this  system  will  immunize  them  against  rabies;  but  to  conclude  from 
this,  that  inoculation  of  patients  already  infected  will  also  be  eflficient, 


100  ACUTE  INFECTIOUS  SURGICAL  DISEASES 

is  not  logical.  From  practical  experience,  however,  it  may  be  said 
that  there  is  no  good  reason  to  doubt  that  inoculation  according  to 
Pasteur's  method,  under  the  latter  circumstances,  has  rendered  most 
of  the  patients  so  treated  immune.  But  it  must  not  be  forgotten  that 
the  vast  majority  of  patients  treated  in  Pasteur  Institutes  never 
would  have  developed  rabies  under  any  circumstances;  many  of 
them  are  bitten  by  animals  that  are  not  rabid;  and  therefore  their 
inoculation  in  most  instances  is  perfectly  useless.  Moreover,  there 
is  not  a  shadow  of  doubt  that  in  a  few  well  authenticated  cases  no 
immunity  has  been  procured  by  the  inoculations,  the  patients  sub- 
sequently developing  and  dying  from  the  disease;  and  it  has  even 
been  open  to  suspicion  that  these  very  patients  might  have  been 
among  that  large  number  who,  even  without  the  inoculations,  never 
would  have  developed  the  disease — in  other  words,  that  the  danger 
of  contracting  rabies  as  the  result  of  the  inoculations,  though  very 
remote,  is  not  altogether  imaginary.  The  actual  mortality  attending 
the  Pasteur  treatment  is  given  as  less  than  1  per  cent, ;  but  as  from 
these  statistics  it  is  customary  to  exclude  all  those  patients  who 
develop  rabies  within  fifteen  days  after  the  last  inoculation  (Rambaud), 
the  number  of  those  in  whom  immunity  is  actually  produced  is  con- 
siderably less  than  would  appear  if  this  fact  were  not  taken  into  con- 
sideration. Before  a  surgeon  recommends  the  preventive  treatment 
by  inoculation  he  should,  I  think,  place  all  these  facts  plainly  before 
the  patient;  and  if  the  patient  wishes  to  take  this  very  remote  risk, 
and  the  surgeon  is  convinced  that  he  was  infected  by  a  rabid  animal, 
no  time  should  be  lost  in  having  this  treatment  instituted. 

The  curative  treatment  is  nearly  hopeless.  Hyoscin  and  curare, 
hypodermically,  are  the  best  drugs;  chloral  and  morphin  have  little 
effect.  Proctoclysis  of  saline  solution,  with  large  doses  of  bromides 
by  the  rectum,  may  be  tried.  Amyl  nitrite  or  chloroform  may  be  used 
for  the  convulsions.     The  saliva  should  be  sterilized. 


CHAPTER    IV. 
TUMORS. 

In  studying  tlic  iiiHanimatory  ])rocess  it  was  seen  that  the  local 
reaction  induced  was  usually  sufficient  to  overcome  and  destroy  the 
origin  of  the  trouble;  in  the  case  of  the  infectious  granulomas,  instead 
of  an  efficient  reaction,  the  indications  of  inflanunation  were  found  to 
be  very  slight,  and  cellular  proliferation  was  the  main  characteristic 
of  the  process.  Yet  in  both  these  instances  the  cell  proliferation  was 
incontestably  in  the  nature  of  a  reaction  to  external  stimulus.  In 
tumors  we  find  a  pathological  process  characterized  by  purposeless, 
more  or  less  unlimited,  cellular  proliferation  of  unknown  cause,  pro- 
ducing practically  no  reaction  in  surrounding  tissues.  The  cells  of 
tumors  seem  to  be  a  law  unto  themselves:  they  do  not  follow  the 
ordinary  processes  which  subserve  the  purposes  of  the  organism  as 
a  whole;  their  only  function  appears  to  be  proliferation,  and  this 
they  evince  without  discoverable  purpose  or  known  cause. 

For  an  understanding  of  tumor  processes  a  knowledge  of  embry- 
ology is  necessary,  because  the  most  logical  classification  of  tumors 
which  has  yet  been  proposed  (Adami,  1902)^  is  that  based  on  their 
histogenetic  characteristics,  and  because  the  ultimate  cause  of  tumor 
formation  seems  to  lie  in  inherent  characteristics  of  the  cells  them- 
selves, not  in  stimulus  from  without  nor  in  relief  from  constraint  by 
surrounding  structures. 

Definition. — This  is  difficult,  because  the  cause  of  tumors  is  not 
known;  a  definition  therefore  has  to  be  formed  solely  from  the  objective 
characteristics  of  fully  formed  tumors.  Adami  accepts  as  satisfactory 
the  statement  of  C.  P.  White  that  "a  tumor  is  a  7nass  of  cells,  tissues, 
or  organs  resembling  those  normally  'present,  but  arranged  atypically. 
It  grows  at  the  expense  of  the  organism  icithout  at  the  same  time  sub- 
serving any  nsefnl  function." 

GENERAL  CHARACTERISTICS  OF  TUMORS. 

The  word  tumor  means  a  swelling,  and  all  tumors  are  character- 
ized by  a  more  or  less  localized  swelling,  which  usually  is  both  visible 
and  palpable.  Tumors  may  be  multiple  or  single,  may  occur  at  any 
age,  and  in  any  situation. 

Form. — A  tumor  growing  on  the  surface  of  the  body  assumes  a 
typically  rounded  form  (Fig.  49) ;  one  in  the  internal  organs,  or  beneath 

1  In  the  following  paragraphs  the  teaching  of  Adami,  and  sometimes  his  words, 
have  been  closely  followed. 


102 


TUMORS 


a  resistant  fascia,  or  compressed  by  other  parts  of  the  body  will  spread 
ill  the  direction  of  least  resistance;  tumors  may  thus  become  irregular 

in  form  (nodular,  ])aj)illary,  etc.). 
Consistency  ^'aries  greatly,  being 
dc})enden t  upt  m  the  ty i)e  of  tumor : 
fatty  tumors  are  soft,  bony  and 
cartilaginous,  are  hard  fibromas 
and  are  more  or  less  firm.  Rate  of 
Growth:  This  is  usually  slow,  the 
increase  in  size  being  measured 
by  months  or  years  rather  than 
by  weeks  or  days;  in  general,  the 
more  rapid  the  growth,  the  worse 
the  prognosis.  Slowly  growing 
tumors  seem  to  pro^'oke  a  feeble 
reaction  in  the  surrounding  tis- 
sues, so  that  they  become  sur- 
rounded by  a  more  or  less  well 
defined  capsule;  those  of  rapid 
growth  extend  into  normal  tissues 
in  various  directions  before  a  cap- 
sule can  l)e  formed.  Manner  of 
Growth:     Growth    occurs   simul- 

FiG.  49. — Lipoma  of  right  arm.  ,  i      •         ii  ,        e       ^ 

taneously  in  all  parts  or  a  tumor, 
not  only  at  the  periphery  or  in  the  centre,  though  in  certain  tumors 
growth  at  one  place  is  much  more  marked  than  at  others.  The  more 
rapid  the  growth,  the  more 
apt  are  the  central  cells  to  be 
squeezed  out  of  existence,  and 
therefore  in  such  tumors  cen- 
tral degeneration  is  common, 
leading  at  times  to  cyst  for- 
mation. Size  varies  so  greatly 
that  no  clear  statement  can 
be  made  (Figs.  50  and  51). 

Malignancy.  —  From  the 
above  it  is  evident  that  cer- 
tain tumors  are  less  benign 
than  others.  Even  tumors 
recognized  as  clearly  benign 
may  be  dangerous  from  their 
size  or  position.  The  size  of 
a  tumor  may  impair  the 
patient's  health  by  requiring 
an  extraordinary  amount  of 
nourishment;  its  position, 
even  if  small,  may  threaten  ^i«-  so.-Papiiioma  of  face. 

life,  as  in  growths  of  the  larynx  threatening  suffocation,  in  the  ali- 
mentary canal  causing  obstruction,  or  in  the  brain  causing  pressure 


TIIEORJES  OF  rUMOR  FORMATIOS 


103 


oil  vital  centres.  But  tumors  conii);ir;iti\ely  sniiill  in  si/.c  iind  innocu- 
ous in  position  may  by  their  inherent  ciiaracteristics  be  exceedingly 
dangerous  to  life.  These  characteristics  are  (Adami):  Embryonic 
character  of  the  tumor  cells,  leading  to  rapid  growth;  this  in  turn  gives 
the  surrounding  tissues  no  opportunity  to  encapsulate  the  growth, 
with  the  result  that  itifiltration  of  the  surrounding  tissues  occurs,  this 
infiltration  extending  far  beyond  the  limits  visible  to  the  naked  eye 
or  discoverable  by  palpation.  Metastasis:  Some  of  the  tumor  cells  by 
their  rapid  growth  may  break  into  bloodvessels  and  be  carried  by  the 
blood  to  the  nearest  set  of  capillaries,  and  may  even  pass  through 
these  (pulmonic,  hepatic)  and  enter 
the  next  set,  in  either  situation 
lodging  and,  unless  killed  by  the 
tissues  of  the  part  in  which  they  are 
arrested,  giving  rise  there  to  new 
growths  {metastases)  similar  to  the 
original  tumor.  (It  is  held  by 
Orth  and  certain  other  pathologists 
that  normal  cells  surrounding  evi- 
dently malignant  cells  may  become 
infected  by  the  latter,  and  them- 
selves aid  in  the  formation  of  the 
tumors.  I  think  it  is  more  reason- 
able to  consider,  with  Ribbert, 
Adami,  and  others,  that  metastases 
are  due  to  the  proliferation  solely 
of  cells  which  have  been  trans- 
ported from  the  primary  tumor.) 
The  tendency  to  central  degenera- 
tion and  cyst  formation  has  already 
been  alluded  to;  in  addition,  super- 
ficial parts,  those  furthest  removed 
from  the  blood-supply,  whether  on 
mucous  or  cutaneous  surfaces,  tend 
to  sloughing  and  ulceration.  These 
malignant  tumors,  moreover,  tend 

to  return  after  removal  (recurrence) ,  either  because  this  was  incom- 
plete in  the  first  place,  or  because  other  previously  normal  cells  become 
anarchistic  in  their  turn.  Further,  malignant  tumors  produce  cachexia; 
this  is  not  in  any  sense  a  specific  cachexia,  but  is  caused  by  the  drain 
on  the  natural  resources  of  the  body  by  the  tumor,  by  anemia  due  to 
hemorrhages  from  its  ulcerated  surface,  by  toxemia  through  absorp- 
tion, or  by  intoxication  from  perverted  metabolism. 


Fig.  51. — Excision  of  right  clavicle  for 
alveolar  sarcoma,  March  3,  1894,  at  age 
of  nineteen  years.  Recurrent  growth  re- 
moved April  20, 1895.  Present  recurrence 
noticed  September  1896.  Grew  very  rap- 
idly after  April,  1897.  From  a  patient  in 
the  University  Hospital  under  the  care  of 
the  late  Prof.  John  Ashhurst. 


THEORIES  OF  TUMOR  FORMATION. 

Most  of  the  theories  in  favor  at  the  present  day  account  only  for 
one  or  two  types  of  tumor.     Cohnheiins  theory  is  to  the  effect  that 


104  TUMORS 

during  fetal  life  certain  groups  of  cells  become  displaced  from  their 
normal  site,  remain  undeveloped  and  latent  (cell  "rests")  until  some 
future  period  of  adult  life,  and  then  from  some  unknown  cause  begin 
to  proliferate  and  form  a  tumor;  this  theory  accounts  very  well  for 
tumors  of  distinctly  fetal  origin  (teratomas),  but  there  are  many 
other  tumors  which  under  no  circumstances  can  be  considered  due 
to  cell  rests.  Ribbert's  theory,  a  modification  of  Cohnheim's,  sup- 
poses that,  besides  fetal  displacement,  also  post-natal  displacement 
of  nests  of  cells  may  occur;  but  that  proliferation  of  such  displaced 
cells  is  not  due  to  stimulation  from  without  nor  to  any  inherent 
qualities  of  the  cells  themselves,  but  to  lack  of  restraint  by  the  sur- 
roimding  tissues.  Yet,  in  the  process  of  regeneration  (p.  30)  cells 
exhibit  such  qualities  in  marked  degree,  yet  no  tumor  results  except 
in  most  exceptional  instances.  Parasitic  Theory:  This  is  based 
chiefly  on  observations  which  tend  to  show  the  infectiousness  of  cer- 
tain malignant  tumors;  such  tumors  (carcinoma  and  sarcoma)  may 
be  transplanted  from  animal  to  animal,  their  virulence,  if  it  may  be 
so  called,  being  markedly  increased  by  passing  them  through  series 
of  susceptible  animals;  and  in  many  such  tumors  parasites  of  various 
kinds  have  been  found.  But  the  parasites  are  of  various  kinds,  their 
etiological  value  has  not  been  proved,  and  even  if  it  were,  this  theory 
would  explain  the  growth  of  only  one  class  of  tumors — the  malignant. 
This  reduces  us,  therefore,  to  the  theory  that  the  origin  of  tumors  lies 
in  perverted  habits  of  the  cells  themselves,  however  it  may  be  aided 
by  the  abnormal  position  of  the  cells  (Cohnheim),  by  their  release 
from  restraint  (Ribbert),  or  by  their  stimulation  by  parasitic  forms  of 
life.  The  utmost  that  we  definitely  know  of  tumor  cells  is,  as  Adami 
puts  it,  that  they  have  gained  the  habit  of  growth,  and  have  lost  that  of 
function. 

CLASSIFICATION  OF  TUMORS. 

Functional  development  of  cells  necessitates  their  specialization. 
The  most  undeveloped  cells  are  said  to  be  toti-potential  (capal)le  of 
everything) ;  more  developed  cells  are  pluri-jMential  (capable  of  more 
than  one  thing) ;  while  cells  which  are  most  developed  are  uni-jjotential 
(capable  of  only  one  thing)  (Barfurth).  Basing  his  ideas  of  the 
nature  of  tumors  on  the  inherent  properties  of  the  cells  themselves, 
Adami  recognizes  three  main  groups  of  tumors,  according  to  whether 
the  tumor  arises  (1)  from  absolutely  undifferentiated  (toti-potential) 
embryonal  cells,  (2)  from  partially  differentiated  (pluri-potential) 
embryonal  cells,  or  (3)  from  uni-potential  cells,  that  is,  cells  which 
can  form  only  one  type  of  tissue.  The  first  class  (Teratoma)  is  deri^'ed 
from  cells  which  might  possibly,  at  a  later  period,  be  developed  into 
any  form  of  tissue  or  any  organ,  or  even  into  a  complete  individual. 
The  third  class  (Blastoma)  is  derived  from  cells  which  (before  the 
tumor  originates)  ha\e  so  far  developed  that  they  can  give  rise  to 
only  one  form  of  tissue,  e.  g.,  connective  tissue  cells  can  produce  only 
connective  tissue  tumors,  epithelial  cells  can  produce  only  epithelial 


CLASSIFICATION  OF  TUMORS 


105 


tumors,  etc.  Tlio  second  or  iiitcrnu'diarN-  ty])C  of  tumor  (Terato- 
blastomaj  is  (lcri\ cd  i'rom  cells  only  so  far  dilferentiated  that  tliey  can 
produce  more  than  one  form  of  tissue,  l)ut  not  all  forms  (Fig.  ")2). 
Tumors  composed  only  of  one  tissue  are  rare. 


Fig.  52.— Diagrammatic  representation  of  section  through  vertebrate  Ijody  to  show 
ontogenetic  relationship  of  the  various  orders  of  tissues.  A.  Of  Icpidio  type:  1,  epiderm 
and  its  glands  (cpiblastic) ;  2,  mucous  membrane  of  digestive  canal  and  its  glands,  liver, 
etc.  (hypoblastic) ;  3,  endothelium  lining  serous  cavities  (mesoblastic)  and  glands,  like 
renal  cortex,  of  mesothelial  origin;  4,  vascular  endothelium  of  late  mesoblastic  origin. 
B.  Of  hylic  type:  5,  spinal  cord,  brain,  and  nerves  (epiblastic) ;  6,  notochord  (hypo- 
blastic) ;  7,  connective  tissues  of  the  body  (mesenchymatous) ;  8,  myotomes,  striated 
muscle  of  body  (mesothelial).  C.  Cavities:  9,  lumen  of  digestive  tube;  10,  body  cavity. 
(Adami  and  McCrae.) 


Teratomas. — These  are  divided  by  Adami  into  two  main  classes, 
according  to  whether  the  teratoma  is  derived  from  the  same  indi- 
vidual as  the  person  possessing  the  tumor,  or  Avhether  it  is  derived 
from  a  twin  which,  becoming  atrophic  in  embryonal  or  early  fetal  life, 
remains  only  as  a  fetal  inclvsion.  This  latter  class  produces  the 
various  forms  of  monsters,  chiefly  of  interest  to  obstetricians.  The 
former  class  comprises  those  tumors  usually  known  by  the  name 
teratoma.    These  tumors  may  spring  from  germinal  cells,  or  from  non- 


106 


TUMORS 


germinal  cells;  in  the  former  instance  the  tumor  is  foimd  in  the  ovary 
(ovarian  "dermoid"),  where  a  large  cyst  is  usually  formed,  or  in  the 
testicle,  where  the  growth  (rare)  is  chiefly  solid,  with  only  a  small 
cyst;  while  in  the  latter  instance  the  most  frequent  site  is  at  one  end 
of'  the  cerebrosi)inal  axis  (epignathus,  sacral  teratoma).  As  such 
tumors  spring  from  toti-potential  cells,  they  may  include  all  varieties 
of  tissues.  If  the  tumor  contains  elements  formed  from  all  three  of 
the  germinal  layers  it  is  known  as  an  embryoma.  Epithelial  struc- 
tures are  most  frequently  found,  especially  hair  and  teeth  (epiblast), 
or  glandular  tissue  (epi-  or  hypoblast) ;  occasionally  cartilage  or  bone 
(mesoblast). 

These  tumors  usually  are  present  at  birth  (Fig.  53),  but  frequently 
are  not  noticed  until  puberty.     Their  size,  shape,  and  consistency 

vary    according    to    their    location 

n'^^'llipil^^^lH  and  the  structures  composing  them. 
^^^^1  They  usually  grow  rapidly  when 
^^^1  growth  once  begins,  and  may  become 
jWH  malignant,  giving  rise  to  metastases. 
^iiP'''*4^  ^  jtfl  They  are  best  treated  by  excision;  but 
n^^^  -c!>w>." *!^B  i^i  the  newborn  operation  should  be 
postponed  until  it  is  apparent  that  the 
child's  constitution  is  otherwise  suf- 
ficient to  support  life. 

Terato-blastomas.^ — These  tumors, 
derived  from  pluri-potential  cells, 
comprise  most  of  the  so-called 
"mixed  tumors" — tumors  in  which 
tissues  are  found  which  do  not  nor- 
mally exist  in  the  organ  or  tissue 
affected.  In  the  parotid,  and  sometimes  in  the  submaxillary  gland, 
cartilaginous  tumors  are  not  unusual;  in  the  kidney  such  tumors 
rarely  have  more  than  one  variety  of  aberrant  tissue,  and  have 
received  various  names  according  to  the  predominant  tissue — rhab- 
domyoma, adenosarcoma,  etc.  The  tumor  known  as  chorio-epithelioma 
(deciduoma)  maligmnn  belongs  to  this  group;  it  is  formed  by  neoplastic 
development  of  cells  of  the  chorionic  villi.  The  placerital  mole  is 
believed  to  be  the  early  stage  of  such  development;  when  the  cells 
invade  the  uterine  sinuses  malignancy  is  evident  and  the  deciduoma 
is  present. 

The  terato-blastomas,  as  well  as  the  pure  embryomas,  often  exhibit 
malignant  characteristics,  and  are  best  treated  by  excision. 

Blastemas. — ^These  tumors,  forming  by  far  the  largest  group  of 
neoplasms,  result  from  the  independent  growth  of  uni-potential  cells. 
They  are  divided  by  Adami  into  two  main  groups,  according  as  they 
are  composed  chiefly  of  cells  arranged  like  epithelial,  or  rind,  tissues 
(Lepidic  tumors,  Lepidomas),  or  of  cells  arranged  like  the  stroma  or 
pulp  of  tissues  and  organs  {Hylic  Tumors,  Hylomas).  The  charac- 
teristic of  all  epithelial  structures  (skin,  mucous  mem])rane,  endo- 


FiG.  53.  — •  Sacro-coccygeal  tera- 
toma. Italian  girl,  aged  six  months. 
Pennsylvania  Hospital. 


LIPOMA 


Wi 


tlu'liuin)  is  that  tlu'  cells  jirc  ])l;i(r(l  closely  toj^ctluT,  there  heiiiij;  ;in 
ahseiice  ot"  deliiiite  stroma  hetween  the  indixidiiai  cells,  and  no  blood- 
vessels penetrating  hetween  the  \arioiis  <;Ton|)s  of  cells.  The  ciiar- 
acteristic  of  all  i)nli)  tissnes  (nerxons  tissm\  nniscle,  hone,  etc.)  is  that 
the  specific  cells  lie  in  and  are  sei)arate(l  hy  a  definite  stroma,  in 
which  hlood  and  lym|)h  \(>ssels  may  or  may  not  he  present.  Lepidic 
and  hylic  tnmors  may  be  either  typical  or  atypical.  The  typical  blas- 
temas are  slow  growing,  and  their  structure  approaches  that  of  normal 
adult  tissue;  the  atypical  l)lastomas  are  composed  of  rather  immature 
cells,  do  not  closely  resemble  adult  tissue,  and  grow  raj)i(lly.  Typical 
blastomas  are  more  or  less  encapsulated;  the  atypical  are  infiltrating. 
Typical  blastomas  are  benign,  atypical  blastomas  are  malignant. 

E.xamples  of  typical  (benign)  lepidic  tumors  are  papilloma,  adenoma; 
of  hylic  tumors,  are  fibroma,  osteoma.  Examples  of  atyj)ical  (malig- 
nant) lepidic  tumors  are  epitlwlioma,  carcinoma;  of  atypical  hylic 
tumors  are  the  numerous  varieties  of  sarcoma. 

In  addition  to  distinct  tumors,  certain  blastomatoid  f/rouihs  (Adami) 
must  also  be  recognized;  they  approach  more  closely  the  reacti^■e 
changes  of  infianunation,  and  correspond  to 
the  "continuous  hypertrophies"  or  "out- 
growths" of  Paget  (1853)  as  distinguished 
from  the  true  tumor  or  "discontinuous 
hypertroj)hy"  of  that  author. 

Typical  (Benign)  Hylic  Tumors. — The  most 
important  of  these  are  tumors  resembling 
the  following  normal  tissues:  Fat  (Lipoma); 
Fibrous  Tissue  (Fibroma);  Cartilage  (Chon- 
droma); and  Bone  (Osteoma).  Although 
many  varieties  of  tissue  may  exist  in  the 
same  tumor,  yet  one  usually  is  so  predomi- 
nant as  to  give  its  name  to  the  growth.  If 
another  tissue  is  present  in  fairly  large 
amount,  a  compound  term  is  used,  thus  fibro- 
lipoma,  the  tissue  present  in  greatest  abun- 
dance always  being  named  last. 

Lipoma. — This  may  consist  rather  in  an 
hypertrophy  of  fat  normally  present  (lipo- 
matosis, a  "continuous  hypertrophy  or  out- 
growth") than  in  an  actual  tumor.  Multiple 
lipomas  are  not  rare  (Fig.  54).  A  lipoma 
rarely  is  well  encapsulated.  It  grows  slowly, 
produces  no  discomfort  except  from  its  size 
or  position,  and  is  absolutely  benign.  The 
skin  over  it  is  not  discolored  nor  adherent, 
though  a  slight  dimpling  may  be  present  oc- 
casionally, from  fibrous  bands  supporting  the 

tumor  between  the  skin  and  deep  fascia.  It  is  soft,  easily  movable 
on  the  underlying  tissues,  and  semi-fluctuating.     A  lipoma  sometimes 


Fig.  54.  —  Lipomatosis 
aiTecting  only  the  extremi- 
ties, aged  fifty-one  years. 
Began  at  fourteen  years. 
Father  had  the  same  con- 
dition.   Episcopal  Hospital. 


108 


TUMORS 


will  gradually  shift  its  position  under  the  force  of  gravity.  It  may  occur 
oil  any  part  of  the  body,  and  occasionally  in  the  sub-peritoneal  fat 
or  omentum.  Its  seats  of  predilection  are  the  limbs,  trunk,  and  neck 
(Fig.  55).  It  frequently  is  fibrous  in  character,  then  being  firmer 
than  a  pure  lipoma  (Fig.  50).  It  may  be  attached  })y  a  j)edicle  deep 
down  in  a  muscular  interspace,  occasionally  to  periosteum.  ^Mucoid 
degeneration  may  occur  (my.vo-lipoma) ,  especially  in  internal  lipomas. 

Diagnosis  may  be  aided  by  freezing  the  growth,  whereupon  it  will 
become  hard. 

Treatment. — If  any  treatment  is  required,  excision  should  be  done. 


Fig.  55. — Lipoma  of  neck,  duration 
nineteen  years.  Very  soft,  almost  fluctu- 
ating. (Not  goitre;  not  attached  to 
larynx;  does  not  rise  in  swallowing.) 
Episcopal  Hospital. 


Fig.  56. — Fibro-lipoma  of  right  cheek 
in  a  girl,  aged  fifteen  years;  growing 
slowly  for  last  nine  years.  Sight  of  left 
eye  lost  from  smallpox  in  infancy. 
Episcopal  Hospital. 


Xanthoma. — Xanthoma  is  a  small  flattened  benign  fatty  and  fibrous 
tumor  in  the  skin,  whose  nature  is  not  well  understood.  It  is  named 
from  its  yellow  color,  occurs  most  frequently  around  the  eyes,  and 
is  sometimes  seen  in  persons'  with  gall-bladder  disease.  Usually  no 
treatment  is  required. 

Fibroma. — Tumors  consisting  solely  of  fibrous  tissue  are  rare;  they 
usually  are  small  (Fig.  57),  frequently  multiple,  grow  slowly,  and  are  well 
encapsulated.  Depending  upon  the  amount  of  fibrous  tissue  present, 
fibromas  are  named  hard  or  soft.  The  latter  is  the  more  frequent 
variety,  and  is  well  represented  by  the  mucous  polypi  growing  in  the 
naso-pharynx.  The  tumor  is  firm  to  the  touch,  pale  and  glistening 
on  section,  with  a  capsule  usually  demonstrable.  The  favorite  sites 
of  development  are  the  subcutaneous  tissues,  along  nerve  trunks, 
in  periosteum,  fascia,  the  uterus  and  mammary  gland.  Some  of  these 
must  be  regarded  as  fibroid  over-growths  rather  than  as  distinct  tumors, 
e.  g.,  fibroma  molluscum.    Fibromas  frequently  undergo  degeneration, 


FIBROMA 


109 


Fig.  57. — Fibroma  pendulum.    Episcopal  Hospital. 


particularly  tlir  iiiucoid,  forming'  a  tiiinor  known  as  myxoma;  tliis  is 

especially   t're(|uent   in  nnicons    [)()lyps;  a  tnnior  in  or   hetween   the 

<j;luteal  nnisclcs  usnally  is  a 

fibro-myxoma.      Malignant 

elianu'cs  arc  hy  no  means 

rare,   the    cells    remainin*;' 

ininiature.  and  prolit'erat- 

in<;'   with   niuhie  aetivity, 

forniinji;  the  fibrosarcoma; 

)N!/.ro-.sarr()ni(t  also  occurs, 

as  well  as  internal  hemor- 

rliaii;e  with  cyst  formation. 
Dlaf/nosis. — Diagnosis  is 

made  1)\'  notinji;  the  long 

duration;  indolent  growth; 

firm  consistence;  rounded, 

apparently     encapsulated 

character;      and      normal 

overlying  skin. 

Treatment. —  Frequently 

none  is  required;  but  any 

suspicion    of    malignancy 

(Fig.  58),  arousefl  by  rapid  growth,  apparent  myxomatous  or  cystic 

changes,  etc.,  justifies  prompt  extirpation.     Recurrence  is  not  very 

rare,  even  after  removal  of  an  apparently  benign  tumor,  and,  as  a 

rule,  the  recurrent  is  more  malignant  than  the  primary  growth. 

Keloid  or  Cheloid.  —  The  hyper- 
trophied  condition  of  scars,  known  as 
the  keloid  of  Alihert,^  is  really  a  form 
of  fibroma  affecting  the  subepithelial 
tissues.  It  almost  invariably  follows 
some  irritation,  though  individual 
predisposition  has  much  to  do  with 
its  development.  Thus  it  is  often 
seen  in  the  negro  race  (Fig.  59);  it 
may  develop  in  the  scars  of  burns,  or 
of  comparatively  simple  operations 
(Fig.  60).  There  is  some  evidence 
that  it  is  of  tuberculous  origin.  It 
is  a  crab-like  (keloid)  or  scar-like 
(cheloid)  out-growth,  covered  by 
red,  tense,  shiny  epithelium;  it  may 
extend  into  sound  tissues  in  various 
directions.    It  usually  is  tender,  and 

irritation  increases  its  size.      Occasionally  the  out-growths  disappear 

spontaneously;  they  usually  recur  after  excision. 

1  To  distinguish  it  from  the  Keloid  of  Addison  (Morphoea),  an  affection  belonging 
rather  to  dermatology  than  surgery. 


Fig.  58. — Fibroma  of  back,  malig- 
nant degeneration.  Patient  aged 
seventy-three  years;  duration  fifteen 
years.     Episcopal  Hospital. 


no 


TUMORS 


Treatment. — Treatment  consists  in  protecting  them  from  irritation 
by  the  clothes  or  opposing  parts  of  the  body.    Ointments  of  tar  and 

zinc,  with  animal  rather  than 
mineral  bases,  are  valuable. 
Thiosinamin  (5  to  10  per  cent, 
solution)  hypodermically,  is 
recommended  by  Park  (1907). 
Chondroma. — A  tumor  com- 
posed chiefly  of  cartilage.  If 
it  springs  from  preexisting 
cartilage  cells  it  is  termed 
ecchondroma  (cartilaginous 
out-growth);  if  from  other 
forms  of  connective  tissue, 
especially  fibrous,  it  is  called 
enchondroma  (cartilaginous 
tumor).  Its  occurrence  as  a 
terato-blastoma  was  referred 
to  at  p.  106.  Chondromas  are 
of  stony  hardness,  unless  de- 
generated; usually  more  or 
less  lobulated,  grow  slowly, 
but  usually  faster  than  lipomas 
or  fibromas,  the  growth  occur- 
ring chiefly  at  the  periphery; 
are  painless,  immovable,  fre- 
quently multiple  ;  seldom  affect 
the  overlying  skin;  and  are  generally  quite  benign,  but  liable  to  form 
metastases.  They  are  especially  prone  to  mucoid  degeneration,  and 
when  such  occurs  malig- 
nancy should  be  suspected. 
Sarcomatous  changes  are 
not  unusual.  True  bony 
changes  (osteo-chondroma) 
sometimes  occur.  If  the 
skin  sloughs,  the  cystic 
contents  of  the  degener- 
ated chondroma  may  dis- 
charge, leaving  a  most 
intractable  sinus. 

Ecchondromas  arise  from 
epiphyseal  lines  before 
adult  life,  and  later  also 
from  articular,  costal,  and 
intervertebral  cartilages, 
larynx,  trachea,  etc.  En- 
chondromas  spring  from 
from  articular  cartilages, 
cially  in  the  rachitic;  affect  especially  the  phalanges,  the  flat  bones 


Fiii.  39. — Keloid  (of  Aliheit  J  in  scars  following 
a  whipping  from  patient's  mother.  Patient  of 
the  late  Dr.  Isaac  Massey,  of  West  Chester,  Pa. 


Fig.  60. — Keloid  in  .scar  of  neck.  Had  lirush  burn 
in  1907,  and  keloid  was  excised  one  month  later. 
Keloid  recurred,  and  present  photograph  made  one 
year  after  recurrence.     Episcopal  Hosjiital. 


periosteum   or    bone    marrow,    but    not 
Chondromas  develop  in  early  life,  espe- 


OSTEOMA 


111 


({ielvis,  scapula,  skull),  the  fcnuir,  aud  tlu'  uiaxilla.  When  growiiifj^ 
on  tho  surfaci'  of  a  bono,  beneath  the  ixTiosteuni,  they  may  wear  away 
its  surface,  leaving  a  distinct  (le])ressi()n  when  they  are  removed. 

Diagnosis. — They  are  to  be  distinguished  from  bony  tumors  by 
their  occurrence  in  younger  patients,  by  their  situation,  and  by  their 
multiplicity;  but  a  differentiation  is  not  always  i)ossible  without  the 
•T-rays.     Cartilage  casts  no  shadow,  or  at  most  a  very  light  one. 

Treatment. — Chondromas  should  be  completely  extirpated  when- 
ever possible.  Incomplete  removal  favors  recurrence,  and  the  recur- 
rences are  more  inclined  to  malignancy  than  the  primary  growths. 
Amputation,  except  of  the  phalanges,  is  rarely  required. 

Osteoma. — A  true  tumor  com- 
posed solely  of  bone  is  decidedly 
rare;  most  so-called  bony  tumors 
are  really  only  osseous  hypertro- 
phies. True  osteoma  may  ari.se 
on  the  surface  of,  or  within  the 
substance  of  bone.    In  the  former 


Fig.  61. — Multiple  ecchondromas  of 
finger.     (Shepherd.) 


Fig.  62. — Osteoma  of  upper  jaw.  Four 
years'  standing.  From  a  patient  in  the 
University  Hospital  under  the  care  of  the 
late  Prof.  John  Ashhurst,  Jr. 


instance  it  grows  beneath  the  periosteum ;  in  the  latter  it  grows  from 
the  medulla,  being  then  known  as  endosteoma.  Either  form  may 
be  composed  of  spongy  or  of  compact  bone.  The  tumor  grows  by 
cellular  proliferation  of  its  own  elements,  not  from  participation  of 
elements  in  the  surrounding  bone;  these  latter  are  compressed,  pushed 
aside,  and  eventually  disappear  before  the  ongrowing  tumor.  Thus 
a  periosteal  osteoma  will  excavate  the  underlying  bone,  while  an 
endosteoma  will  penetrate  it,  break  through  the  cortical  bone,  and 
grow  more  freely  when  thus  reheved  from  pressure.    Occasionally  an 


112  TUMORS 

osteoma  occurs  in  tissue  which  normally  contains  no  bone.  Such  a 
tumor  is  a  heteroplastic  osteoma;  it  is  possible  that  it  develops  from 
a  fetal  milage,  but  usually  it  arises  in  a  piece  of  cartilage  or  periosteum 
which  has  been  displaced  by  trauma  in  post-natal  existence.  That 
true  bone  can  form  in  chondromas  has  already  been  noted. 

Ostoses. — A  diffuse  bony  out-growth  is  called  a  hyperostosis;  a  cir- 
cumscriljed,  more  or  less  sessile  out-growth  is  an  exostosis;  a  projecting 
growth  with  narrow  base  is  an  osteophyte;  while  an  osseous  out-growth 
occurring  in  the  centre  of  a  bone  (e.  g.,  arising  from  the  diploe)  is  termed 
an  endostosis  or  enostosis.  Occasionally  an  ostosis  of  one  form  or 
another  appears  to  become  neoplastic  in  nature,  exhibiting  autonomous 
proliferation.  Exostoses,  which  are  the  most  frequent  of  the  bony 
hyperplasias,  usually  are  multiple,  and  very  difficult  to  distinguish 
from  multiple  ecchondromas,  especially  as  ossifying  changes  in  the 
latter  are  l)y  no  means  rare.  They  occur  in  the  same  situations  (except 
that  exostoses  are  very  rare  on  the  hands),  present  the  same  charac- 
teristics, and  run  the  same  clinical  course.  The  imry  exostosis  of  the 
skull  is  an  exception,  which  it  is  usually  possible  to  distinguish 
clinically.  It  is  extremely  hard,  and  if  growing  from  the  diploe 
(enostosis)  may  be  as  prominent  on  the  dural  as  on  the  pericranial 
surface.  Ostoses  are  sometimes  developed  in  the  accessory  sinuses  of 
the  face.  Bony  changes  occurring  in  tendons,  muscles,  etc.,  are  referred 
to  at  p.  274. 

Diagnosis. — Diagnosis,  especially  of  endosteomas  and  enostoses, 
may  be  impossible  without  the  use  of  the  a'-rays,  by  which  the  denser 
shadow  of  osseous  growths  may  sometimes  be  distinguished  from  that 
cast  by  cartilaginous  tumors. 

Treatment. — Rarely  is  any  required,  unless  removal  of  one  or  more 
circumscribed  out-growths  is  necessary  to  relieve  pressure  on  nerves, 
bloodvessels,  the  brain,  etc.  Recurrence  after  thorough  extirpation 
is  exceptional. 

Odontoma. — The  teeth  are  developed  from  epiblast  and  mesoblast, 
and  while  a  tumor  having  its  origin  in  either  element  may  occur  in 
man,  the  vast  majority  of  odontomas  are  derived  from  the  epithelial 
portion,  and  are  seen  as  "cysts  lined  with  columnar  or  cuboidal 
epithelium  or  containing  gland-like  areas  in  their  w^all"  (Simmons, 
1907).  This  form,  known  also  as  adamantinoma,  usually  springs  from 
the  lower  jaw,  the  tumor  growing  in  and  slowly  distending  the  body  of 
the  bone ;  it  is  composed  of  multilocular  cysts,  with  a  bony  framework 
(multilocular  dentigerous  cyst) .  It  occurs  especially  in  young  females, 
is  of  slow  growth,  and  usually  symptomless  except  when  causing  pres- 
sure on  neighboring  parts.  Crackling  may  be  detected  on  palpation 
if  the  growth  has  thinned  the  overlying  bone.  Usually  there  is  an 
unerupted  tooth  present. 

Diagnosis.- — Diagnosis  sometimes  is  difficult,  especially  from  sar- 
coma. Carcinoma  is  more  frequent  on  the  upper  jaw  in  older  patients, 
and  ulceration  is  common.  Exostoses  and  chondromas  are  denser  and 
the  .r-ravs  max  reveal  the  cvstic  nature  of  the  adamantinoma.  Sarcoma 


MYELOMA  113 

in  this  sitiuition  usually  is  periosteal  in  orij^in,  grows  rapidly,  c|uickly 
invades  the  soft  parts,  is  not  cystic,  and  presents  no  "egg-shell" 
crackling. 

Trcaiiiicnt. — Opening  the  growth,  and  destroying  its  interior  tiior- 
onghly  with  the  shar])  spoon  and  actual  cautery,  usually  effects  a  cure. 
It  is  essentially  henign.  The  o})eration  may  be  done  from  within  the 
mouth. 

Myeloma. — The  bone  marrow  contains  two  chief  varieties  of  cells — 
those  having  to  do  directly  with  bone,  and  those  supplying  the  blood. 
Adami  classes  under  this  section  tumors  derived  from  true  bone 
marrow  (osteogenetic)  cells,  and  certain  blastomatoid  conditions  due 
to  disturbances  of  the  l)lood  cell  elements  in  the  marrow. 

Giant-ccUcd  Myeloma. — ^This,  frequently  spoken  of  as  giant-celled 
sarcoma,  is  too  little  malignant  to  be  classed  with  atypical  hylic  tumors. 
It  is  composed  of  large  numbers  of  myeloplaxes  (giant  cells  of  bone 
marrow)  lying  in  a  matrix  formed  by  spindle  or  polygonal  cells  of  fibro- 
blastic tyj)e.  The  tumor  may  develop  beneath  periosteum,  sometimes 
occurs  in  the  lower  jaw  or  cla\'icle,  but  usually  arises  in  the  interior 
of  the  shafts  of  long  bones,  near  the  epiphyses;  it  is  almost  the  only 
tumor  found  in  the  radius;  it  occurs  in  the  young,  grows  slow^ly,  and 
expands  the  overlying  bone,  which  may  become  so  thin  as  to  crackle 
on  pressure  {sj/ina  ventosa).  The  tumor  itself  is  rather  soft,  quite 
vascular,  and  when  sectioned  resembles  splenic  tissue  or  even  currant 
jelly;  if  it  breaks  through  its  bony  capsule  pulsation  and  occa- 
sionally bruit  are  present  {false  osteoid  aneurysm) .  (See  p.  446.)  Spon- 
taneous fracture  is  rare.  The  lymphatic  system  is  not  affected  in 
pure  myeloma;  no  metastases  occur;  and  if  the  tumor  is  thoroughly 
removed  recurrence  is  unlikely.  Occasionally,  however,  the  tumor 
undergoes  sarcomatous  change,  the  stroma  cells  being  small,  growth 
rapid,  and  recurrence  usual. 

Diagnosis.- — A  slowly  growing  tumor,  in  the  interior  of  a  bone, 
and  near  the  epiphysis  if  in  a  long  bone,  occurring  before  twenty-five 
years  of  age,  and  not  producing  cachexia  or  metastasis,  is  usually  a 
giant-celled  mveloma.  The  diagnosis  from  bone  cvsts  is  discussed  at 
p.  446. 

Treatment. — Usually  it  is  sufficient  to  cut  aw^ay  the  overlying  bone, 
clean  out  the  tumor  tissue,  scrape  and  thoroughly  cauterize  the  walls 
of  the  cavity;  but  it  is  safer  in  case  of  recurrence  to  excise  the  whole 
end  of  the  bone  affected.  Amputation  should  be  done  for  invasion 
of  the  soft  parts. 

Myelomatosis. — This  blastomatoid  condition  effects  the  red  bone 
marrow  chiefly  of  the  vertebrae,  ribs,  and  cranium;  it  is  a  primary 
nwltiple  process  (Borst).  The  growths  are  yellowish  red,  pulpy,  and 
firm,  and  though  it  is  due  (Adami)  to  proliferation  of  the  blood-forming 
elements  of  the  marrow,  there  is  in  orthodox  cases  no  involvement 
of  the  lymphatic  system  or  spleen  (such  a  condition  being  called 
myelogenous  leukemia).  Albumosuria  (Bence-Jones)  is  frequent  in 
myelomatosis,  and  relations  of  this  disease  to  osteomalacia  are  not 


114  TUMORS 

clear.  Treatment  is  sometimes  required  because  out-growths  in  the 
vertebrae  press  on  the  cord;  excision  should  be  done. 

Chloroma. — Chloroma,  according  to  Adami,  is  an  aberrant  type  of 
myelomatosis;  it  is  a  rather  malignant,  multiple  growth  of  greenish- 
yellow  tint,  affecting  especially  the  face  bones;  and  is  frequently 
associated  with  myeloblastic  leukemia   (Dock). 

Lymphomatosis. — As  myelomatosis  is  due  to  proliferation  of  blood- 
forming  marrow  cells  (myeloblasts,  which  produce  leukocytes),  so 
lymphomatosis  is  a  corresponding  state  due  to  hyperplasia  of  lympho- 
blasts.  There  are  many  affections  characterized  by  widespread 
enlargement  of  lymphatic  tissue,  notably  tuberculosis;  there  are  others, 
probably,  but  not  certainly  tuberculous;  and  there  is  Hodgkin's 
disease,  of  unknown  cause  (p.  271);  levkemia  is  still  another,  but  has 
no  surgical  interest.  Adami,  in  addition  to  the  above  blastomatoid 
conditions,  admits  the  existence  of  typical  lymphoma;  but  far  more 
frequent  is  atyjncal  lymphoma,  comprising  the  various  forms  of  lympho- 
sarcoma (p.  272). 

Myoma. — The  leiomyoma  is  a  tumor  composed  of  smooth  muscle 
fibres,  arranged  in  various  directions,  and  inclosed  in  a  fibrous  stroma 
(fibromyoma).  The  older  the  tumor  the  more  does  fibrous  tissue 
preponderate,  so  that  finally  muscular  fibres  may  be  inconspicuous 
(fibroids) ;  this  change  may  be  a  mere  over-growth  of  fibrous  tissue,  or 
an  actual  metaplasia  of  muscle  fibres  (Adami).  It  occurs  with  over- 
whelming frequency  in  the  uterus  (p.  1102),  but  occasionally  is  found  in 
other  portions  of  the  genito-urinary  system  or  in  the  digestive  tract, 
where  the  stomach  is  most  often  affected  (49  cases  collected  by  Deaver 
and  Ashhurst  in  1909).  The  tumors  are  usually  multiple,  may  attain 
immense  size,  and  frequently  require  excision. 

Rhabdomyoma. — The  occurrence  of  this  tumor,  except  in  connec- 
tion with  terato-blastomas  (p.  100),  is  almost  unknown.  It  appears 
usually  to  be  malignant. 

Neuroma. — A  true  ganglionar-celled  neuroma  is  so  rare  as  to  be  of 
no  interest  surgically.  False  neuromas  are  fibrous  "out-growths" 
occurring  upon  nerves  (fibromatosis  nervorum).  Amputation  neuromas 
are  somewhat  similar  (p.  200). 

Glioma. — This  is  a  tumor  developed  from  the  stroma  of  nerve 
tissue  (neurogha)  (Fig.  63) ;  it  is  found,  with  few  exceptions  (retina, 
cerebral  nerves),  in  the  brain;  and  may  be  either  hard  (when  pro- 
jecting into  the  ventricles) ;  or  soft,  when  it  infiltrates  the  cerebral 
hemisphere  without  any  attempt  at  encapsulation  fp.  582). 

Chordoma. — Chordoma  is  a  rare  tumor  growing  from  bone  in  the 
region  of  the  pituitary  body,  and  developed  from  remains  of  the  noto- 
chord. 

Atypical  (Malignant)  Hylic  Tumors. — Sarcoma. — The  characteristics 
of  malignancy  in  general  (p.  KJoj  and  of  atypical  blastomas  in  par- 
ticular (p.  107)  have  already  been  considered.  Sarcomas  are  atypical 
hylomas  of  mesenchymal  origin,  all  possessing  this  peculiarity,  that 
they  are  composed  of  embryonic  connective  tissue  cells.     Sarcoma 


SARCOMA 


115 


may,  therefore,  occur  wherever  connective  tissue  exists;  indeed,  as 
pointed  out  by  Bland-Sutton  (1906),  it  may  be  regarded  as  a  malig- 
nant tumor  disease  of  connective  tissue.  Sarcoma  occurs  by  prefer- 
ence, however,  in  bone,  periosteum,  fascia,  ligaments,  tendons,  brain, 
ovaries,  testicles,  and  skin;  less  often  in  the  lungs,  muscles,  uterus, 
liver,  and  intestines.  It  grows  rapidly,  by  cellular  proliferation  in  all 
parts  of  the  tumor,  frequently  assumes  a  lobular  appearance,  infiltrates 
in  all  directions,  particularly  along  and  inside  of  bloodvessels,  and 
early  gives  rise  to  metastasis  through  the  blood-stream.  Though 
most  sarcomas  infiltrate  equally  in  all  directions,  certain  tumors  extend 
in  finger-like  processes  here  and  there,  giving  an  organoid  appearance 
to  the  section.  Such  growths  have  been  termed  alveolar  and  tubular 
sarcomas.     A  special   characteristic  of  all   sarcomas  is  the  extreme 


Fig.  63. — A,  from  the  more  typic'al  portion  of  a  glioma.    B.  Another  region  from  same 
growth  of  more  malignant  type,  a  true  gliosarcoma.     (Thomas  and  Hamilton.) 

meagreness  of  the  stroma  present;  only  with  difficulty  may  stroma 
be  detected",  so  closely  are  the  sarcoma  cells  packed  together.  Sar- 
comas are  highly  vascular,  and  the  walls  of  the  bloodvessels  are  com- 
posed solely  of  endothelial  cells;  the  sarcoma  cells  lie  in  immediate 
contact  with  the  outer  surface  of  the  endothelium,  and  frequently 
grow  inside  the  vessels.  A  characteristic  of  rapid  growth  and  of 
the  vascularity  of  these  tumors  is  their  liability  to  myxomatous  and 
other  degenerations,  to  internal  hemorrhages,  and  to  cyst  formation 
(p.  103). 

Sarcomas  are  classified  according  to  the  form  and  size  of  their 
component  cells  into  small  round-celled,  large  round-celled,  and  spindle- 
celled  sarcomas  (Fig.  6-1  and  65);  or,  where  several  kinds  coexist, 
mixed-celled  sarcomas.    The  smaller  the  cell  and  the  less  the  amount 


116 


TUMORS 


of  stroma,  the  more  malignant  is  the  sarcoma;  therefore,  the  large 
spindle-celled  sarcoma  (formerly  called  "recurrent  fibroid")  is  the 
least  malignant,  probably  because  in  the  others  the  cells  are  less 
developed,  the  most  so  in  this.  The  form  of  the  sarcoma  cell 
depends  on  the  structure  from  which  it  is  derived;  thus,  as  pointed 
out  by  Adami,  only  cells  Avhich,  in  the  course  of  their  normal  develop- 
ment,*^ pass  through  a  spindle-celled  stage  can  give  rise  to  spindle- 
celled  sarcoma  (connective  tissue  cells,  plain  muscle  fibres,  etc.); 
whereas  round-celled  sarcomas  are  developed  from  cells  such  as 
lymphocytes,  which  even  when  normally  matured  are  still  round. 
Finally,  calling  the  above  2^i<re  sarcomas,  a  group  of  iritermediate 
sarcomas  may  be  recognized,  in  which  some  of  the  cells  develop  beyond 
the  embryonal  stage  sufficiently  to  give  a  tissue  characteristic  to  the 
tumor,  but  do  not  reach  full  adult  maturity: /tro^arcow? a,  lympho- 
sarcoma,  osteosarcoma,  chondrosarcoma,  gliosarcoma,  etc. 


wwKmz-f%^. 


|9©^ 


&&'hs. 


he. 


^r^^ 


Fig.  6-i. — Small  round-celled  sarcoma 
from  skin.  (High  magnification.)  (From 
Professor  Klotz.) 


Fig.  65. — Spindle-celled  sarcoma  (recur- 
rent, from  forearm) :  a,  delicate-walled 
bloodvessel  in  tumor.  (From  Professor 
Klotz.) 


It  is  an  interesting  question,  as  yet  undecided  by  pathologists, 
whether  the  term  sarcoma  shall  be  applied  to  a  tumor  composed  of 
any  cells  other  than  connective  tissue  cells.  Thus,  if,  for  example,  a 
sarcomatous  tumor  is  found  in  (smooth)  muscle  tissue,  it  may  have 
originated  (1)  by  sarcomatous  proliferation  of  the  connective  tissue 
cells  (not  muscle  cells)  in  the  tissue  of  a  normal  muscle  or  of  a  typical 
leiomyoma  (p.  114);  (2)  by  malignant  proliferation  ah  initio  of  the 
muscle  cells  themselves;  or  (3)  by  a  secondary  sarcomatous  change 
(anaplasia)  aflPecting  the  muscle  cells  in  a  previously  formed  myoma. 
To  the  first  tumor  the  name  myosarcoma  is  properly  applied;  the 
second,  which  many  hold  is  not  truly  a  sarcoma,  is  best  described  as 
a  malifjnant  myoma;  while  the  third  is  distinguishable  from  the  others 
by  the  term  myoma  sarcomatodes.    According  to  Adami,  this  last  is 


SARrOMA 


117 


pr{)l)al)ly  the  most  frequent  form;  but  most  i)atlu)l()sists,  I  believe, 
still  roj^artl  the  first  as  the  most  usual.  The  same  question  arises  in 
connection  with  <i;lionia,  lyi)h()ma,  endothelioma,  etc.,  and  also  with 
osteosarcoma,  fibrosarcoma,  etc.,  thouffh  not  so  i)ointcdly  in  these 
latter,  because  they  are  formed  of  connective  tissue  alone. 

Diagnosis. — Sarcoma  occurs  usually  in  the  young  (over  forty  years 
it  is  quite  rare),  not  infrequently  follows  trauma,  grows  rapidly 
(weeks  and  months),  causes  early  metastasis,  especially  in  the  lungs 
and  skin;  is  frcciuently  hot,  and  painful;  and  eventually  produces 
cachexia.  It  is  firm  but  not  bony  to  the  touch  if  growing  from  bone 
or  cartilage;  rather  soft  if  in  fibrous  tissue  or  the  viscera. 


Fig.  66. — Inoperable  sarcoma  of  pelvis;  rapid  growth  after  exploratory  laparotomy 
six  months  ago.     Note  ecchymosis  of  hip  from  recent  bruise.     Children's  Hospital. 


Prognosis. — This  is  gloomy.  Recurrences  are  almost  inevitable; 
and  even  if  no  recurrence  occurs  locally,  visceral  metastases,  unde- 
tected at  time  of  operation,  almost  surely  kill  within  two  or  three 


vears. 


Treatment. — Prompt  extirpation,  which  often  but  not  always 
implies  amputation  of  the  limbs,  and  wide  cutting  excision  of  other 
parts,  offers  the  only  chance  of  cure.  Reoperation  for  local  recur- 
rences sometimes  prolongs  life,  though  rarely  effecting  a  cure.  If 
the  tumor  is  inoperable  when  first  seen,  treatment  with  Coley's  fluid 
should  be  tried;  and  in  all  cases  it  is  well  to  use  this  after  operation. 
The  mixed  toxins  of  the  B.  prodigiosus  and  streptococcus,  introduced 
by  Coley  of  New  York  in  1892,  are  administered  hypodermically, 
either  into  the  growth  itself  or  its  immediate  neighborhood  (initial 
dose  I  to  ^  a  minim),  or  in  other  parts  of  the  body  (initial  dose  1 
minim),  the  dose  gradually  being  increased  so  that  it  is  no  more  than 
sufficient  to  cause  febrile  reaction  analogous  to  that  seen  with  tuber- 
culin (p.  81).  It  has  been  a  clinical  observation  for  nearly  fifty 
years  that  attacks  of  erysipelas  occasionally  had  a  healing  influence 
on  malignant  growths;  and  it  is  not  an  illogical  theory  that  bacterial 
toxins  might  influence  tumor  cells  favorably,  reducing  the  process 
more  nearlj'^  to  that  of  an  inflammatory  reaction.  As  a  matter  of 
fact,  the  use  of  Coley's  fluid,  especially  in  his  own  hands,  has  secured 
some  surprisingly  favorable  results:  in  a  few  instances  permanent 


118 


TUMORS 


cure  has  followed;  in  many  the  tumors  have  been  reduced  to  operable 
states,  or  have  been  kept  in  abeyance,  as  it  were,  for  sometimes  they 
grow  again  when  treatment  is  discontinued;  in  some,  recurrence 
seems  to  have  been  prevented.  My  own  experience  with  Coley's 
fluid  has  been  very  limited,  but  on  the  whole  favorable;  the  tumor 
has  at  least  grown  smaller,  and  the  pain  and  discomfort  of  the  patient 
been  noticeably  relieved. 

Typical  (Benign)  Lepidic  Tumors. — PapUloma. — This  is  an  epithelial 
tumor  growing  from  skin  or  mucous  membrane  (Fig.  50).  It  projects 
above  the  surface,  sometimes  as  a  single  nodular  mass,  sometimes  as  a 
definitely  papillomatous  out-growth.  Its  nourishment  is  derived  from 
vessels  which  are  carried  to  it  in  a  core  of  the  underlying  connective 


Fig.  67. — Papilloma  of  bladder  to 
show  the  long,  finger-like  papillomatous 
outgrowths.     (Ribbert.) 


Fig.  68. — Intracystic  papilloma  of  breast. 
(Orth.) 


tissue;  but  the  connective  tissue  itself  typically  undergoes  no 
blastomatous  change,  merely  growing  as  required  by  the  inde- 
pendent growth  of  overlying  epithelium.  Most  so-called  papillomas 
(warts,  etc.,  p.  259)  are  clearly  not  neoplasms,  but  hyperplasias  due 
to  chronic  irritation.  Some  of  the  mucous  polypi  described  as  soft 
fibromas  (p.  108)  may  be  considered  as  forms  of  papilloma,  if  it  is  the 
epithelium  and  not  the  connective  tissue  core  which  becomes  blasto- 
matous; the  question  is  very  hard  to  decide.  True  papillomas  occur 
chiefly  on  mucous  surfaces,  especially  the  urinary  bladder,  where  the 
tumor  is  composed  of  numerous  fine  finger-like  projections  (Fig. 
67);  stomach  (polyposis);  rectum;  uterus,  etc.  Similar  tumors  often 
grow  from  the  mucous  lining  of  cysts,  especially  in  cystic  adenomas 
{intracystic  ■papillomas)  (Fig.  68). 


CARCINO\fA  119 

Treatment. — As  malignant  changes  (carcinoma)  are  not  very  un- 
common, papillomas  arc  best  treated  by  excision;  and,  unless  this  is 
thorough,  recurrence  is  frequent,  es})ecially  in  the  bladder. 

Adenoma.^ — Instead  of  the  lining  membrane  presenting  out-growths, 
as  in  the  case  of  i)ai)illoma,  in-ijrotrths  may  occur;  as  this  cliange  is 
almost  limited  to  preformed  glands,  the  resulting  neoplasm  is  called 
an  adenoma.  It  is  not  a  very  common  tumor,  being  encountered 
most  often  in  the  mamma,  thyroid,  liver,  prostate,  and  around  the 
margins  of  gastric  ulcers.  In  the  two  latter  situations  it  is  j)robable 
that  the  change  is  one  of  adenomatosis,  a  hyperplastic  reaction  to 
chronic  irritation.  The  more  important  adenomas  are  discussed  in 
connection  with  transitional  lepidomas  (p.  127).  The  true  adenoma 
probably  always  originates  in  cell  rests;  it  is  well  encapsulated,  and 
has  no  conununication  through  ducts  with  the  excretory  channels  of 
the  gland  in  which  it  lies.  The  cells  forming  an  adenoma  usually 
retain  some  of  their  glandular  characteristics,  and  may  secrete  a 
modified  form  of  the  natural  product;  this  secretion  then  distends  the 
acini,  and  a  cysiadenoma  is  produced.  Into  these  cysts  papillomatous 
growths  frequently  occur  (Fig.  68),  producing  intracystic  ijainlloma; 
or  cystadenoma  j^ciinlliferwn.  Here  again  it  is  exceedingly  difficult 
to  tell  whether  the  projectioxis  are  truly  papillomatous  or  whether 
they  are  only  apparently  papillomatous,  being  caused  by  the  adjacent 
in-growth  of  adenomatous  cells.  In  many  adenomas  the  fibrous  stroma 
is  markedly  increased  {fibroadenoma),  and  it  is  held  by  some  that 
neoplastic  proliferation  of  this  stroma  is  the  cause  of  the  papilloma- 
tous intracystic  projections,  and  that  the  epithelium  overlying  the 
projections  is  entirely  passive.  The  cells  of  an  adenoma  always  lie 
upon  a  well  developed  basement  membrane,  which  invariably  sepa- 
rates them  from  the  underlying  stroma ;  when  the  tumor  grows  rapidly 
this  basement  membrane  may  be  poorly  developed;  and  when  it  is 
absent,  and  the  epithelial  cells  have  broken  through,  lying  in  immediate 
contact  with  the  stroma,  the  tumor  can  no  longer  be  considered  an 
adenoma:  it  has  undergone  malignant  (carcinomatous)  change.  Bland- 
Sutton  (1906)  denies  that  such  a  change  ever  occurs.  An  adenoma 
may  be  very  small,  or  extremely  large  and  ponderous;  the  smaller, 
harder,  tumors  of  the  breast  are  usually  painful. 

Treatment. — Adenomas  should  be  removed  whenever  possible;  espe- 
cially does  rapid  growth  render  this  imperative.  Recurrence  is  not 
to  be  feared;  and  metastasis  is  unknown. 

Atypical  (Malignant)  Lepidic  Tumors. — Carcinoma. — This  includes 
all  malignant  tumors  of  epiblastic  or  hypoblastic  origin.  Under 
carcinoma  of  epiblastic  origiji  are  included  all  skin  cancers,  as  well  as 
cancers  derived  from  the  mammary  and  other  epidermal  glands, 
epithelium  of  mouth,  salivary  glands,  naso-pharj^nx,  etc.;  while  those 
of  hypoblastic  origin  include  carcinoma  of  the  digestive  tract,  pancreas, 
liver,  bladder,  and  respiratory  tract,  thyroid,  thymus,  tonsils,  etc. 
Although  the  cause  of  carcinoma  is  totally  unknown,  most  cases  occur 
in  persons  over  forty  years  of  age,  and  it  is  most  frequent  in  sites 


120  TUMORS 

which  have  h)ii^  been  su})jected  to  irritation,  or  in  which  unhealed 
and  chronically  irritated  ulcers  exist — e.  g.,  lacerations  of  the  cervix 
uteri,  gastric  ulcer,  smokers'  cancer  of  the  lower  lip,  syphilitic  ulcers 
of  the  tonj^ue,  chimney-sweep's  (soot)  cancer  of  the  scrotum,  cancer  of 
the  skin  in  workers  in  paraffin,  pitch,  chrome,  etc. 

Carcinoma  is  due  to  the  independent  (autonomous)  growth  of  epi- 
thelial cells;  and  this  growth  is  atypical.  That  is  to  say,  it  differs  not 
only  from  the  growth  of  epithelial  cells  seen  in  regeneration  (healing 
of  ulcers),  but  it  also  differs  from  the  growth  of  epithelial  cells  seen  in 
an  adenoma.  In  an  adenoma,  for  instance,  the  epithelial  cells  retain 
to  a  certain  degree  their  normal  character;  they  line  the  gland  tubules 
or  acini,  leaving  usually  a  distinct  lumen,  and  rarely  forming  more 
than  one  layer  around  this  central  lumen;  and  they  are  always  placed 
on  a  distinct  l;asement  membrane.  In  carcinoma,  on  the  other  hand, 
the  in-growths  of  epithelial  cells  are  usually  solid,  finger-like  masses; 
there  is  no  lumen,  except  in  certain  cancers  derived  from  preformed 
glands,  and  even  then  the  cells  tend  to  pile  upon  each  other  around 
the  periphery  and  to  encroach  on  the  lumen;  the  basement  mem- 
brane is  absent,  and  the  masses  of  epithelial  cells  are  in  direct  contact 
with  the  surrounding  tissues.  When  seen  in  cross-section  it  appears 
as  if  there  were  cell  nests  entirely  detached,  lying  in  the  connective 
tissues;  but  rarely,  if  ever,  is  this  the  case.  It  has  been  shown  by  serial 
sections  (Petersen)  that  these  are  directly  continuous  with  the  sur- 
face epithelium,  being  one  of  the  claws  of  the  crab-like  growth  which 
gives   cancer   its   name. 

Not  only  does  carcinoma  extend  in  all  directions  into  all  surround- 
ing tissues,  but  it  has  a  very  extraordinary  tendency  to  extend  along 
lymphatic  channels.  It  was  formerly  thought  that  this  extension  was 
largely  in  the  way  of  metastasis,  i.  e.,  that  groups  of  carcinoma  cells 
were  detached  from  the  main  tumor  and  carried  in  the  lymph  current 
away  from  their  site  of  origin,  until,  lodged  in  the  nearest  lymph  nodes, 
they  there  set  up  a  metastatic  growth  entirely  separate  from  the  main 
tumor,  leaving  uninvolved  tissue  between.  That  this  sometimes  occurs 
may  not  be  denied,  but  it  is  certain,  owing  chiefly  to  the  researches 
of  Handley  (1905)  in  relation  to  mammary  carcinoma,  that  in  the 
vast  majority  of  cases  such  extension  occurs  by  direct  continuity 
(permeation)  along  the  lymphatic  spaces  of  the  deep  fascia,  and  along 
lymph  vessels,  and  that  the  affected  lymph  nodes  are  connected  icith 
the  primary  tumor  by  innumerable  fine  cords  of  carcinoma  cells.  When 
the  lymph  nodes  are  invaded,  dissemination  beyond  them  may  occur, 
the  carcinoma  cells  eventually  entering  the  blood-stream  and  being 
widely  disseminated  in  the  lungs,  spine,  etc.  Occasionally,  dissemina- 
tion by  the  blood  occurs  early,  before  the  adjacent  lymph  nodes  are 
palpably  affected.  These  secondary  growths,  wherever  found,  repro- 
duce the  character  of  the  primary  tumor;  we  may  find  in  the  humerus 
a  secondary  nodule  with  the  characteristics  of  the  glands  of  the  rectum, 
nodules  in  the  ovary  with  the  features  of  the  mammary  gland,  etc. 
Secondary  deposits  are  rarest  in  muscle,  most  frequent  in  the  skin, 


EPITHELIOMA 


121 


lun^s,  and  bono,  especially  the  vertebrie,  as  well  as  in  organs  anatoniie- 
ally  related  to  the  j^riniary  f^rowth. 

Two  main  varieties  of  carcinoma  may  he  reco<,nii/,ed:  J-'/jilliclioiiKi 
and  (I'ldiidiilar  ('(irriiioiiia. 

Epithelioma.  Thou^di  this  term  is  ajjplied  hy  the  French  to  all 
malignant  tumors  of  ei)ithelial  origin,  it  is  customary  among  P^nglish 
speaking  surgeons  to  limit  it  to  squamous-celled  carcinoma,  and  it  is 
so  used  in  this  volume.  It  affects  the  skin,  especially  muco-cutaneous 
junctures  (lips,  anus,  glans  penis,  vulva),  mouth,  tongue,  pharynx, 
eso])hagus,  etc.  \'ery  exceptionally  epithelioma  has  heen  found  where 
no  squamous  epithelium  normally  exists  (gall-hladder,  stomach, 
uterus,  etc.).  Pre-rancrroiis  changes  are  well  recognized  clinically. 
Among  those  of  most  importance  are  the  senile  or  seborrheic  patch 
{hrrafosis,  p.  0-2);  lenloplakia  (p.  (547);  and  Paget' >>  di.s-ca.se  (p.  719). 
As  already  noted,  any  chronic  irritation  seems  to  pre(iisj)ose  to  the 
development  of  carcinoma. 

Two  forms  of  epithelioma  are  distinguishable,  the  superficial,  and 
the  deep-seated,  of  which  the  last  will  be  described  first. 


m^ 


■■■:  ?) 

\*'y^f,"  ■  ■  '■■'■'.  ■- 


■■::00::B: 


Fig.  69. — Early  epithelioma  of  tongue,  to  show  (a)  region  of  origin  by  down-growth 
from  preexisting  epithelium;  h  b,  epithelial  pearls;  c,  small-celled  infiltration  in  sur- 
rounding tissue.     (Petersen.) 


1.  Deep-seated  Epithelioma. — This,  the  more  frequent  variety, 
commences  as  a  downward  proliferation  of  epithelial  cells  which 
preserve    fairly    well    the  typical   appearance    of    cells   of   the  rete 


122 


TUMORS 


Malpighii,  a  few  "prickle"  cells  frequently  being  discernible.  These 
cells  are  very  slightly  anaplastic:  they  preserve  their  functions  so  far 
that  they  still  tend  to  undergo  horny  changes,  this  keratosis  resulting 

in  the  formation  of  "pearly 
bodies,"  which  are  really  cross- 
sections  of  plugs  in  which  the 
central  cells  have  become  horny,, 
and  being  compressed  by  those 
outside,  produce  a  typical  lami- 
nated appearance  (Fig.  69).  A 
little  round-celled  infiltration 
may  be  seen  around  these  in- 
growths, evidences  of  reaction 
on  the  part  of  the  stroma. 

This  form  of  epithelioma  when 
growing  on  the  skin  usually  is 
first  noticed  by  the  patient  as 
an  induration  (hyper-keratosis), 
commencing  frequently  in  a 
senile  seborrheic  patch  (p.  622). 
Or  it  may  develop  from  a  papil- 
loma (Fig.  70).  Soon  the  centre 
becomes  abraded,  crusts,  ulcer- 
ates, and  gives  thfe  growth  an 
umbilicated  appearance  (Fig. 
71).  This  ulcer  spreads;  its 
edges  may  retain  the  features  of 
the  original  nodule,  but  usually  are  less  firm,  ragged,  and  only  moder- 
ately raised  above  the  base  of  the  ulcer.  It  occurs  especially  on  the 
face  and  hands,  the  lower  lip 
being  a  favorite  site.  The 
neighboring  lymph  nodes  are 
invaded  early  (three  to  five 
months),  and  the  progress  of 
the  disease  is  much  more  rapid 
than  that  form  about  to  be  de- 
scribed. The  stench  from  these 
ulcerated  surfaces  is  some- 
times frightful,  and  alarming 
hemorrhages  may  occur  in  the 
later  stages.  Occasionally, 
early  in  the  course  of  the  dis- 
ease, the  ulcer  is  covered  with 
warty  excrescences  (Papillary 
Epithelioma)  (Fig.  72),  form- 
ing one  variety  of  Marjolin's  ulcer  (p.  58) ;  but  these  warty  granulations 
often  disappear  as  ulceration  progresses. 

Diagnosis. — This  will  be  considered  more  in  detail  in  the  chapters 
devoted  to  regional  surgery.    Any  chronic  ulcer  of  the  skin  or  adjacent 


Fig.  70. — Epithelioma  of  nose;  aged  sixty- 
three  years;  duration  one  year.  (Developing 
in  a  papilloma.)     Episcopal  Hospital 


P"iG.  71. — Epithi'liomaof  hand;  aged  seventy- 
eight  years;  duration  one  year.  Note  um- 
bilicated appearance.     Episcopal  Hospital. 


CLASSIFICATION  OF  TUMORS 


123 


niiu'ous  membranes  should  be  regarded  witli  siis])i('ion.  Epithelioma 
in  leg  ulcers,  though  very  umi.sual,  is  sometimes  seen;  it  is  less  infre- 
quent in  the  heel. 

J*r()(/it(n>is  is  good  if  excision  is  done  early,  before  lym])li  nodes  are 
I)alpably  enlarged;  later,  recurrence  is  frequent. 

Treatment. — Early  excision,  in  one  mass  with  the  adjacent  lymph 
nodes  and  all  intervening  sul)cutaneous  tissue,  is  the  only  form  of 
treatment  which  offers  hope  of  perman- 
ent cure.  If  an  operation  is  contra- 
indicated  for  any  good  reason,  the 
.r-rays  may  be  applied,  and  in  the  very 
earliest  stages  the  ulcer  sometimes  heals 
under  their  influence;  but  recurrence  is 
usual,  and  by  dilly-dallying  with  .r-rays 
the  favorable  time  for  excision  may  be 
lost.  In  some  inoperable  cases  of  ex- 
ternal carcinoma  relief  may  be  secured 
by  desiccation  with  the  high  frequency 
current,  or  by  fulguration.  The  former 
is  suitable  only  for  surface  growths, 
while  fulguration  is  more  useful  for 
deeply  seated  tumors  after  eurettement 
or  partial  extirpation. 

2.  Superficial  Epithelioma  (Ro- 
dent Ulcer,  Jacob's  Ulcer). — This 
was  first  described  as  a  clinical  entity 
by  Jacob  of  Dublin  in  1827.  It  was 
first  recognized  as  a  variety  of  carcinoma 
by  Warren  in  1872. i 

The  epithelial  cells  which  grow  down  from  the  skin  are  extremely 
atypical,  rounded,  polygonal,  or  even  spindle-shaped.  Because  they 
do  not  form  "epithelial  pearls,"  Krompecher  (1903)  has  named  this 
type  of  epithelioma  "basal-celled  carcinoma,"  on  the  theory  that  it 
is  the  only  type  formed  from  basal  cells;  but  Adami  contends  that  all 
epitheliomas  are  so  formed,  and  that  whereas  in  all  others  the  cells 
develop  to  the  horny  stage,  in  the  rodent  ulcer  the  cells  are  unable 
to  do  so  because  they  present  a  higher  degree  of  anaplasia. 

The  favorite  site  of  rodent  ulcer  is  on  the  upper  half  of  the  face, 
especially  near  the  ala  nasi,  on  the  lower  eyelid,  or  the  forehead;  it 
is  almost  unknown  on  other  parts  of  the  body.  It  is  often  preceded 
by  changes  in  the  skin  (keratosis,- etc.,  see  p.  622)  of  an  irritative 
character,  and  rarely  is  recognized  until  a  small  ulcer  has  formed, 
scabbed  over,  and  again  become  ulcerated  several  times.  The  ulcer 
spreads  very  slowly,  gives  little  discharge,  is  painless;  has  raised,  firm, 
glistening  edges;  and  occasionally  heals  in  one  part  while  extending 


Fig.  72. — Papillary  opithelioma 
(superficial  epithelioma  lately  show- 
ing more  malignant  characteris- 
tics); aged  seventy  years;  duration 
five  years.     Episcopal  Hospital. 


^  Borst  and  other  pathologists  class  it  as  an  endothelioma  or  alveolar  sarcoma. 


124 


TUMORS 


in  another  (serpijjinous  ulceration).  It  does  not  attack  the  neighbor- 
ing lymph  nodes,  and,  contrary  to  what  would  be  expected  from  its 
high  grade  of  anaplasia,  is  in  general  much  less  malignant  than  the 
deep-seated  epithelioma  just  described;  but  it  destroys,  surely  if 
slowly,  everything  in  its  course — eating  away  cartilage,  bone,  con- 
tents of  the  orbit,  opening  the  nasal  cavities  and  sometimes  exposing 
the  brain,  before  death  comes.  Sometimes,  after  progressing  slowly 
for  many  years,  the  rodent  ulcer  will  suddenly  take  on  rapid  growth, 
and  assume  the  character  of  a  deep-seated  epithelioma   (Fig.   72). 


Fig.  73. — Rodent  ulcor  invading  or- 
bit, in  a  woman,  aged  thirty-five  years; 
duration  eighteen  months.  (Dr.  W. 
Walker's  case.)     Episcopal  Hospital. 


Fig.  74. — Rodent  ulcer;  duration  over 
five  years.  Eye  destroyed.  Had  so  far 
only  x-ray  treatment.  Now  inoperable. 
Episcopal  Hospital. 


Diagnosis. — It  must  be  distinguished  chiefly  from  the  deep-seated 
epithelioma.  In  rodent  ulcer  the  edges  are  harder,  more  raised, 
glistening,  and  sometimes  covered  with  fine  capillaries;  the  base  of 
the  ulcer  is  flatter  and  not  so  deeply  placed;  secretion  is  less;  growth 
is  much  slower;  the  lymph  nodes  are  not  invaded;  and  microscopical 
examination  of  an  excised  portion  will  show  no  pearly  bodies,  and 
extremely  atypical  cells. 

Prognosis  is  good  with  proper  treatment  sufficiently  early. 

Treatment. — Excision  should  be  done,  but  it  is  not  necessary  to 
remove  the  adjacent  lymph  nodes.  Even  in  advanced  cases  com- 
plete excision  is  seldom  followed  by  recurrence,  so  that  operation 
should  not  be  refused  in  any  case  where  reco^'ery  from  the  operation 
itself  seems  certain.  Very  early  treatment,  by  an  expert,  with  radium 
emanations,  frequently  causes  the  ulcer  to  heal  without  visible  scar; 
but  recurrence  is  not  unknown.  The  remarks  as  to  .r-ray  treatment, 
made  at  p.  12.3,  apply  here.  The  patient  shown  in  Fig.  74  had  been 
treated  for  five  vears  with  the  .^■-ra^■s  before  she  came  to  me  for 


GLANDULAR   (AliClXOMA  125 

surgical  a(l\ico;  she  tlien  was  a  confirmed  alcoholic  and  niorphiiio- 
maniac,  and  the  tumor  was  absolutely  ino|)ral)le. 

Glandular  Carcinoma. — This  is  so-called  because  it  grows  in  glands. 
Two  forms  may  be  recognized,  according  to  the  extent  that  the  tumor 
departs  from  the  typical  glandular  form: 

1.  Adknocahcinoma. — The  less  atypical  forms,  known  as  adeno- 
carcinonui,  arc  composed  of  alveolar  spaces,  lined  with  cells  arranged 
around  their  periphery,  and  rarely  piling  up  on  each  other  so  as  to 
encroach  on  the  lumen.  This  form  is  therefore  known  also  as  colvmnar 
or  ri/lindrical-crlird  carcinoma  (Fig.  To).  By  obstruction  of  the  ducts 
and  continued  secretory  action  of,  or  from  death  and  liquefaction  of 
the  cells,  these  aheoli  may  be  converted  into  cysts  {cy.stadeno-car- 
cinoma).  It  affects  especially  the  rectum,  pylorus  and  lesser  curvature 
of  the  stomach,  cecum,  etc.,  frequently  developing  from  preexisting 
ulcers  or  adenomas;  or  from  polypi,  when  it  is  wont  to  assume  a 
cauliflower-like  or  fungating  api)earance.  It  occurs  also,  but  more 
rarely,  in  the  cervix  uteri,  naso-pharynx,  larynx,  and  gall-bladder; 
also  from  cell-rests  in  the  neck  (})ranchiogenic  carcinoma,  p.  683). 


^ 


Fig,  75. — Microscopic  appearance  of  adenocarcinoma  (cylindrical-celled 
carcinoma)  of  the  rectum.      (Lexer-Bovan.) 

2.  Solid-celled  Carcinoma. — The  most  atypical  form  of  gland 
carcinoma  consists  of  solid  j)lugs  of  epithelial  cells,  there  rarely  being 
any  lumen  whatever  (Fig.  7(3).  All  grades  may  exist  between  this 
form  and  that  previously  described.  Two  main  varieties  of  the 
solid-celled  carcinoma  are  recognized,  dej)ending  upon  the  amount 
of  stroma  present:  when  this  is  excessive,  the  tumor  is  said  to  be  a 
"scirrhus"  (srlrrlums  carclnoina);  when  the  stroma  is  deficient,  and 
the  cellular  elements  conspicuous,  it  is  called  a  medullary  carcinoma, 


126 


TUMORS 


or,  from  its  gross  resemblance  to  the  brain  on  cross-section,  "encepha- 
loid."  When  stroma  and  parenchyma  are  present  in  equal  amount 
it  is  described  as  carcinoma  simplex,  or  "acute  scirrhus."  Solid-celled 
carcinoma  affects  especially  the  mammary  gland  and  the  cervix  uteri, 
though  in  both  situations  various  combinations  of  carcinomatous 
growth  may  be  encountered. 


Fig.  76. — Microscopic  appearance  of  solid-celled  carcinoma,  arising  in  the  neck  of 
the  uterus.     (From  "Diseases  of  Women,"  Bland-Sutton  and  Giles.) 

Gland  carcinoma  is  especially  prone  to  ulceration,  the  ulcer  being 
deeper  than  in  epithelioma,  and  there  being  a  much  greater  tendency 
to  fungosity.  Colloid  degeneration  is  not  unusual,  particularly  in 
carcinomas  of  the  intestinal  tract;  it  is  due,  according  to  Adami,  to 
the  accumulation  within  the  cells  of  modified  mucin  which  they 
cannot  excrete,  the  result  being  that  entire  alveoli  may  be  distended 
with  this  glistening,  translucent  material. 

Symptonts. — The  symptoms  of  gland  carcinoma  depend  so  much 
upon  the  seat  of  the  tumor,  that  their  description  is  best  postponed 
to  the  chapters  on  regional  surgery. 

Prognosis. — Untreated,  or  treated  only  palliati^'ely,  the  expectation 
of  life  in  carcinoma  has  been  estimated  at  eighteen  months  for  the 
medullary,  and  two  and  one-half  years  for  the  scirrhous  variety;  for, 
although,  in  the  latter,  many  patients  survive  three,  five,  or  even  ten 
years,  yet  an  equal  number  die  in  less  than  the  average  period, men- 
tioned. The  prognosis  after  operation  will  be  discussed  with  regional 
surgery. 


TRANSITIONAL  LE  PI  DO  MAS  127 

Treatment.  —  All  operable  carcinomas  should  he  excised,  at  the 
earliest  possible  moment,  in  one  mass  with  the  neighboring  lymph 
nodes;  when  iMoperal)le,  palliative  treatment  consists  in  dressing  the 
ulcer  (of  external  cancers)  with  permanganate  of  potash  or  other 
deodorant,  and  in  giving  such  stimulants,  tonics,  and  anodynes  as 
shall  make  life  endurable.  Certain  palliative  operations  are  applicable 
to  inoperable  internal  carcinomas. 

Transitional  Lepidic  Tumors.  Mesothelioma  and  Endothelioma. — 
In  addition  to  the  classes  of  lepidomas  already  described  (derived 
from  epiblast  and  hypoblast),  Adami  places  in  a  separate  division 
those  tumors  derived  from  mesothelium  and  endothelium.  As  these 
were  themselves  derived  from  the  mesoblast,  and  as  this  in  turn  was 
formed  partly  by  epiblast  and  largely  by  hypoblast,  it  is  but  natural 
to  find  that  mesothelial  and  endothelial  tumors  present  at  times  the 
characters  of  lei)idomas  (epi-or  hypoblast),  at  others  those  of  hylomas 
(mesoblast).  Therefore  they  are  well  named  transitional  lepidomas, 
because  while  they  usually  resemble  ordinary  lepidomas,  they  at 
times  in  whole  or  in  certain  parts  grade  so  imperceptibly  into  hylomas 
that  it  is  impossible  to  say  to  which  class  they  really  belong.  In 
this  group,  embryogenetically  at  least,  belong  the  lepidic  tumors  of 
the  uterus;  as  these  closely  resemble  similar  tumors  of  epiblastic 
(mammary)  and  hypoblastic  (intestinal)  origin,  Adami  supposes  that 
the  epiblast  has  overgrown  the  primary  mesoblast  of  the  genital  tract. 
These  tumors,  however,  frequently  appear  either  sarcomatous  {i.  e., 
mesotheliomatous)  or  endotheliomatous  in  parts,  so  it  is  evident  that 
they  possess  primary  mesoblastic  characteristics.  While  there  are 
typical  transitional  lepidomas  (adenoma),  the  tumors  in  this  group 
most  important  for  the  surgeon  are  atypical  (carcinomatous)  in 
nature.  Adenoma  and  carcinoma  of  the  prostate  are  included  in  this 
class,  as  well  as  rarer  tumors  of  the  ureters,  seminal  vesicles,  and  vas 
deferens;  similar  growths  of  adrenal,  kidney,  ovary,  and  uterus;  also 
mesothelioma  of  the  pleura,  etc.  For  reasons  already  given,  the 
tumors  of  the  uterus  resemble  usually  ordinary  gland  carcinoma.  The 
most  important  surgically  of  all  the  mesotheliomas  is  the  malignant 
growth  of  the  adrenal  gland  known  as  hypernephroma. 

Hypernephroma. — The  medulla  of  the  adrenal  develops  from  the 
nervous  system,  and  its  cortex  from  the  mesothelium,  closely  related  to 
that  which  forms  the  cortex  of  the  kidney.  The  adrenal  medulla  sel- 
dom gives  origin  to  a  tumor;  when  it  does  it  forms  a  ganglioneuroma. 
The  hypernephroma  (alveolar  sarcoma,  angeiosarcoma,  perithelioma, 
carcinoma,  etc.)  springs  from  the  adrenal  cortex,  and  is,  therefore, 
classed  as  a  mesothelioma.  In  it  may  be  clearly  seen  the  transitional 
type  from  carcinomatous  (lepidic)  to  sarcomatous  (hylic)  arrange- 
ment of  the  alveoli  (Fig.  77).  Owing  to  fetal  inclusions  in  ovary  or 
testis,  mesotheliomas  may  occur  also  in  those  organs,  and  more  rarely 
in  the  kidney  itself  (Chapter  XXV).  The  ordinary  hypernephroma 
behaves  as  a  malignant  tumor,  growing  sometimes  to  immense  size, 
invading  the  kidney,  and  possessing  firm  retroperitoneal  connections. 


128 


TUMORS 


The  only  treatment  is  prompt  excision,  which  implies  nephrectomy; 
the  operation  is  difficult  and  bloody,  and  recurrence  is  usual.  Bony 
metastases  occur,  occasionally  only  a  single  metastasis  (Scudder,  1910). 


nbnzi 


nbnzi: 


Fig.  77. — Hypernephroma  of  kidney.  Transition  from  adenomatous  to  sarcomatous 
type  of  growth:  nbnz',  adenomatous  overgrowth  of  solid  columns  or  masses  of  cells 
of  adrenal  type;   nhm",  transition  to  sarcomatous  arrangement;  K,  a  kidney  tubule 

involved  in  the  growth.     (Debernardi.) 

Mesothelioma. — Mesothelioma  may  arise  in  pleura,  peritoneum,  or 
rarely  in  pericardium  or  synovial  membrane.  It  appears  as  a  pseudo- 
inflammatory  thickening  of  the  serous  membrane,  producing  a 
flattened,  nodular  or  fungous  tumor,  composed  of  "elongated  acini, 
lined  with  irregular,  swollen  cells,  .  .  .  resembling  the  curiously 
epithelioid  type  of  cells  we  encounter  in  some  endotheliomas,"  these 
acini  lying  in  an  abundant  fibrous  stroma  (Adami).  I  have  seen  one 
mesothelioma  of  the  pleura,  in  a  child  of  three  years,  not  recognized 
as  such  by  the  surgeon,  who  operated  for  empyema. 

Endothelioma. — From  this  class  should  be  excluded  blood  and  lymph 
vascular  changes  not  truly  blastomatous.  All  such  conditions  as 
nevi,  telangiectases,  etc.,  will  be  discussed  under  surgery  of  the  vascular 
system  (p.  244).  Here  we  have  to  do  only  with  typical  and  atypical 
neoplasms  of  endothelial  tissues.  They  are  classed  as  hemangeio- 
endothelioma  and  lymphangeio-endothelioma ;  surgically  they  are  not 
of  much  interest.  Briefly,  they  are  formed  by  concentric,  and  at  times 
eccentric  proliferation  of  endothelium  of  blood  or  lymph  capillaries. 
An  atypical  hemangeio-endothelioma  of  the  inner  surface  of  the 
cranial  dura  mater,  in  which  calcareous  deposits  have  occurred,  is 
called  a  psammoma.  Perithelioma  is  a  tumor  in  which  the  lymph  cells 
lining  the  perivascular  lymph  spaces  proliferate;  when  hyaline  degen- 
eration occurs  in  these  cells,  the  tumor  is  called  a  ci/lindroma.  The 
growth  occurs  in  the  kidney,  bones,  and  skin.  Endothelioma  occurs 
oftenest  in  the  skin,  in  the  region  of  the  parotid,  in  the  genital  glands, 
bones,  lymph  nodes,  and  dura  (Park,  1907). 

Tumors  of  the  Carotid  Body  (p.  680)  tend  to  the  peritheliomatous 
type. 


CYSTS  129 

Melanoma.-  Tliere  is  great  uiiccrtainty  wiR'tlicr  tliis  tumor  belongs 
among  sarcomas  or  not.  Adami  is  inclined  to  place  it  among  transi- 
tional Icjjidomas.  It  arises  by  atypical  i)r()lifcration  of  tlic  pigment- 
containing  cells  {rliroiiKttophorcs)  of  the  rete  Maipigliii  in  tlu;  skin, 
or  of  similar  cells  in  the  uveal  tract  of  the  eye.  Ordinary  pigmented 
nevi,  which  are  either  congenital  deformities,  or  typical  as  distin- 
guished from  aiy])i('(d  melanomas,  sometimes  become  transformed 
in  adult  life  into  this  most  malignant  type  of  tumor.  Bcgimiing  in 
a  cutaneous  nevus  or  in  the  eye,  a  melanoma  gives  rapid  and  wonder- 
fully widespread  metastasis,  by  both  blood  and  lymph  chamicls,  to 
skin,  internal  organs  (especially  liver),  ])ones,  lungs,  brain,  etc.  The 
only  ircdiincnt  is  wide  excision  or  amputation  before  metastasis  occurs. 

Cholesteatoma. — Cholesteatoma  is  a  tumor  regarded  l)y  15orst  and 
others  as  of  endothelial  origin;  others  (Ziegler)  think  it  ectodermic, 
resembling  ordinary  dermoid  cysts  (p.  130).  The  contents  consist 
of  "white,  pearl-like,  glistening  masses,  which  are  concentrically 
arranged,"  apparently  the  remains  of  compressed  and  cornified 
epithelial  cells.  They  occur  in  the  middle  ear,  pia  mater,  and  urethra. 
The}'  vary  in  size  from  a  cherry  seed  to  a  hen's  egg.  They  may  cause 
pressure  symptoms  in  the  cranium,  or  otitis  media  when  in  the  middle 
ear  (Lexer).     Excision  is  the  best  treatment. 

CYSTS. 

A  cyst  is  an  abnormal  but  encapsulated  collection  of  fluid,  in  a 
cavity  which  is  not  provided  with  any  outlet.  The  fluidity  of  the 
contents  varies  from  liquid  to  semi-solid.  One  cavity  (unilocular) 
or  many  (multilocular)  may  exist.  A  cyst  is  to  be  distinguished  from 
an  abscess,  which  is  not  strictly  encapsulated;  from  dilatations  (ectasia) 
of  normal  channels  (varix,  aneurysm)  which  still  have  an  outlet;  from 
effusions  or  transudations  into  preformed  and  normal  cavities,  which 
are  classed  apart  (hydrops  articuli,  hydrocele,  hygroma,  hydrothorax, 
hydrocephalus,  etc.) — though  such  collections  may  be  encysted;  and 
from  cystomas,  which  is  a  term  sometimes  used  to  describe  neoplasms 
in  which  cysts  form  incidentally  (p.  119);  but  a  distinction  cannot 
always  be  made  clinically  between  cysts  and  cystomas. 

Cysts  may  be  classed  as  Extravasation,  Retention,  and  Parasitic 
Cysts.  All  cysts  tend  to  become  spherical  or  oval  unless  compressed 
by  neighboring  parts. 

Extravasation  Cysts. — These  are  encapsulated  collections  of  fluid 
not  in  a  preexisting  cavity.  An  example  is  the  hematoma,  due  to 
extravasation  of  blood,  which  as  the  result  of  reaction  and  condensa- 
tion in  the  surrounding  structures,  becomes  in  time  encapsulated. 
Certain  bursal  tumors  (p.  281)  may  belong  in  this  class.  Extravasa- 
tion of  lymph,  forming  a  chylous  cyst,  is  very  rare  (p.  268).  Extra- 
vasation of  urine  rarely  forms  a  distinct  cyst. 

Retention  Cysts. — Retention  cysts  arise  in  preexisting  cavities. 
They  form  the  largest  and  most  important  class,  and  may  arise  either 
9 


130 


TUMORS 


because  there  is  no  opening  to  the  cavity,  or  because  the  normal 
opening  is  obstructed.  In  either  case  it  is  evident  that  secretion  or 
transudation  into  the  cyst  must  be  more  rapid  than  absorption. 
Generally  speaking,  these  cysts  may  be  classed  as  post-natal  or 
antenatal  in  origin. 

I.  Of  Post-natal  Origin. — Examples  of  cysts  due  to  obstruction  of 
ducts  are  Raiuila,  Cysfs  of  Bartholin's  Gland,  Galadocele,  Sebaceous 
Cysts,  Hydronephrosis,  Hydrops  Vesicce  Fellece,  etc.  Examples  of  cysts 
formed  in  cavities  normally  having  no  outlet  are  corpora  lutea  and 
iollicular  cysts  of  the  ovary,  cystic  goitre,  etc. 


Fig.  78. — Sequestration  cyst,  or  dermoid  (congenital  at:)normality)  of 
scrotal  raphe.     Episcopal  Hospital. 

Sequestration  Cysts  deserve  separate  mention.  They  are  due  to 
the  sequestration  and  detachment  of  portions  of  the  true  skin  either 
(1)  during  ante-natal  development,  when  they  are  congenital,  and 
occur  along  the  fissural  lines  of  the  body;  or  (2)  are  caused  in  post- 
natal life  by  implantation  of  portions  of  the  true  skin  by  trauma. 
Most  dermoids  belong  to  the  former  class  (Fig.  78),  though  some, 
especially  pilo-nidal  cysts,  are  occasionally  of  post-natal  development. 
Implantation  dermoids  are  seen  in  the  fingers  of  sewing  women,  or 
in  the  faces  of  shavers.  I  have  several  times  excised  from  the  face 
cysts  supposed  to  be  wens,  which  on  opening  were  found  to  contain 
two  or  three  long  hairs  growing  from  the  interior  of  the  c  yst  wall, 
which  in  such  cases  is  lined  with  squamous  epithelium,  not  with 
secreting  cells. 

II.  Of  Ante-natal  Origin. — These  may  be  considered  in  three 
divisions : 

1.  Cysts  Due  to  Persistence  of  Parts  of  Embryonic  Ducts. — Thyro- 
glossal,  Branchial,  Vitello-intestinal,  and  Urachal  Cysts:  the 
"Tubular  Cvsts"  of  Bland-Sutton. 


GENERAL  REMARKS  ON  EXCISION  OF  TUMORS  131 

2.  Cysts  of   Geniio-urinary  Passages: 

(a)  In  the  Male. — Encysted  liydrocele  of  testis,  probably  due  to  per- 
sistence of  the  cmbrj'onic  vasa  ett'erentia. 

(6)  In  the  Female. — From  various  tubules  composing  the  parova- 
rium, and  perhaps  from  the  paroophoron. 

3.  Congenital  Cysts  of  Glandular  Organs. — The  liver  and  kidney 
are  especially  affected.    The  pathology  is  obscure. 

Parasitic  Cysts. — In  man,  two  main  varieties  of  parasitic  cysts 
are  found,  those  due  to  Trichina  Spiralis  and  Tenia  Echinococcus. 
The  trichina,  much  rarer,  forms  very  small  cysts,  oftenest  in  muscles 
(p.  27()).  The  echinococcus,  commonly  known  as  hydatid  cysts,  may 
attain  an  immense  size.  This  parasite  is  an  inhabitant  of  the  intes- 
tinal tract  of  dogs,  and  the  ova  may  gain  entrance  to  the  digestive 
tracts  of  those  who  have  to  do  with  dogs  and  whose  habits  are  not 
very  cleanly.  It  is  a  rather  rare  disease  in  this  country.  The  shell  of 
the  ovum  is  dissolved  by  the  patient's  intestinal  juice,  and  the  larva, 
thus  liberated,  works  its  way  through  the  intestinal  mucosa  usually 
into  a  branch  of  the  portal  vein,  and  thus  reaches  the  liver;  here  it 
proliferates,  and  one  large,  or  innumerable  small,  conglomerate  cyst 
will  be  found  depending  upon  the  stage  of  development.  They  are 
easily  recognized  by  the  "booklets"  they  contain.  The  lungs,  brain, 
and  other  parts  of  the  body  may  also  be  affected.  Treatment  is 
discussed  in  Chapter  XXIV. 


Fig.  79.     Elliptical  incision  for  the  Fig.  80. — Double  S<S  incision  for  the 

removal  of  a  tumor.  removal  of  a  tumor. 

GENERAL  REMARKS  ON  EXCISION  OF  TUMORS. 

The  incision  should  correspond  with  the  natural  folds  of  the  part; 
no  skin  need  be  removed  in  excising  benign  growths  unless  very  large, 
when  the  redundancy  may  be  removed  with  the  tumor  by  an  elliptical 
incision  or  one  in  the  form  of  double  SS  (Figs.  79  and  80) .  If  a  tumor  is 
very  large,  it  is  not  wise  to  make  the  entire  incision  at  once,  as  bleeding 
is  more  easily  controlled  by  working  down  to  the  main  blood-supply 
through  a  small  incision,  and  completing  this  when  the  main  vessels 


132  TUMORS 

have  been  ligated.  IMost  external  (i.  e.,  not  visceral)  tumors  are  exposed 
on  dividing  the  skin  and  superficial  fascia;  if  beneath  the  deep  fascia 
they  should  be  approached  through  the  proper  muscular  interspace. 
A  tumor  which  is  encapsulated  usually  may  be  enucleated,  keeping 
the  scalpel  close  to  the  capsule.  Malignant  tumors  necessitate  the 
removal  of  healthy  tissues  on  all  sides,  and  usually  of  the  overlying 
skin ;  as  they  frequently  extend  along  and  surround  large  bloodvessels, 
careful  dissection  is  required.  Cancers  should  not  be  removed  by 
blunt  dissection:  the  bruising  of  the  tissues  this  entails  causes  egress 
of  malignant  cells  into  the  surrounding  tissues.  A  malignant  tumor 
never  should  be  cut  into  in  the  process  of  removal;  to  do  this  may 
infect  the  entire  wound  with  cancer  cells,  and  may  cause  alarming 
hemorrhage  from  the  tumor  itself  which  it  will  be  very  difficult  to 
control.  If  a  tumor  when  exposed  is  found  to  be  so  placed  that  it 
cannot  be  removed  with  safety,  the  operation  must  be  abandoned; 
in  some  cases  the  pedicle  of  the  tumor  may  be  secured,  and  the  main 
bulk  cut  away;  or  the  main  vessels  may  be  ligated,  to  starve  the 
growth  (p.  655).  In  gastric  and  intestinal  tumors  a  palliative  opera- 
tion is  frequently  possible. 

If  a  tumor,  before  operation,  is  clearly  inoperable,  of  course  no 
attempt  should  be  made  to  remove  it.  Inoperability  may  depend 
on  general  conditions  (the  cachectic  state  of  the  patient,  and 
probability  or  certainty  of  metastases  which  will  kill  the  patient 
within  the  appointed  time  even  if  the  primary  growth  were  removed), 
or  on  the  local  condition ;  fixity  of  the  growth,  especially  in  the  neigh- 
borhood of  great  vessels  is  always  a  sign  to  be  seriously  considered. 
It  is  important  for  the  surgeon  to  have  a  clear  understanding  with  his 
patient  as  to  the  extent  of  the  operation  possible  and  permissible. 
While  often  invading  and  obliterating  veins,  carcinoma  generally 
respects  arteries,  even  when  entirely  surrounding  them  (Crile) ;  so  that 
it  is  usually  possible  to  dissect  the  artery  free.  E\'erything  but  life 
may  be  disregarded  in  operating  for  malignant  growths:  thus  it  is 
entirely  justifiable  to  amputate  the  thigh,  if  a  tumor  is  so  placed  as 
to  necessitate  excision  of  the  popliteal  artery,  w^hich  would  surely 
cause  gangrene;  it  is  proper  to  excise  muscles,  tendons,  bones,  veins, 
arteries  and  even  nerves,  when,  as  in  the  neck,  to  do  so  will  bring  the 
operation  to  a  successful  conclusion  without  jeopardizing  life.  A 
patient  will  not  miss  one  pneumogastric  nerve  or  one  carotid  artery, 
and  as  a  rule  he  will  prefer  to  live  without  a  clavicle  and  Avith  a  power- 
less arm  than  to  keep  his  tiunor  and  die.  In  some  tumors  resection 
of  the  thoracic  or  abdominal  wall  is  necessarj^;  the  greater  part  of  the 
stomach  may  have  to  be  removed  in  one  piece  with  the  transverse 
colon,  or  the  descending  duodenum  eji  masse  with  the  head  of  the 
pancreas. 


CHAPTER    V 

SURGICAL  TECHNIQUE. 

There  are  readily  available  so  many  excellent  works  on  Band- 
aging, Antiseptic  and  Aseptic  Tecliniqne,  Minor  Surgery,  Anesthetics, 
etc.,  that  in  the  present  chapter  little  will  be  attempted  beyond 
discussing  briefly  the  principles  underlying  these  procedures. 

BANDAGING. 

Bandages  are  employed  to  hold  dressings  in  contact  with  a  wound, 
to  maintain  splints  in  position,  or  simply  to  support  the  part.  Those 
most  generally  useful  are  made  of  unbleached  muslin,  which  may  be 
torn  into  any  width.  For  the  fingers  a  bandage  should  be  one  inch 
in  width;  for  the  head  and  neck,  two  inches;  for  the  forearm,  two 
inches  and  a  half;  for  the  arm  and  leg,  three  inches;  for  the  thigh  and 
shoulder,  three  inches  and  a  half;  and  for  the  trunk,  four  inches  wide. 
The  length  varies  with  the  part  to  be  bandaged  and  with  the  purpose 
for  which  the  bandage  is  employed:  the  finger  bandages  are  usually 
one  or  two,  and  the  larger  from  seven  to  nine  yards  in  length.  When 
prepared  for  use  a  bandage  is  rolled  tightly  into  the  form  of  a  cylin- 
der (roller  bandage),  the  free  end  being  known  as  the  initial  extremity. 
To  roll  a  bandage  by  hand,  fold  one  end  on  itself  for  about  six  inches; 
again  fold  it  in  half,  thus  making  four  thicknesses  of  three  inches  each ; 
again  fold  it  in  half,  making  eight  thicknesses  an  inch  and  a  half  long; 
and  keep  folding  the  bandage  on  itself  until  a  solid  core  is  formed. 
This  core  is  then  held  in  the  left  hand,  between  the  thumb  and  first 
two  fingers,  and  the  free  end  is  firmly  but  tightly  grasped  in  the  web 
of  the  right  thumb  (Fig.  81);  then  by  alternately  supinating  and 
pronating  the  left  hand,  rotating  the  roller  in  supination  but  relaxing 
the  grip  on  it  during  pronation,  the  free  end  of  the  bandage  is  guided 
on  to  the  roller,  which  increases  in  size  at  each  turn  of  the  hand. 
The  right  hand  should  keep  the  bandage  taut,  so  as  to  make  the 
roller  as  firm  as  possible.  A  mechanical  bandage  winder  is  useful  in 
hospitals  or  wherever  many  bandages  are  to  be  rolled. 

In  applying  a  bandage,  the  initial  extremity  is  placed  on  the  part, 
and  the  roller  carried  around  the  limb  transversely  from  left  to  right, 
once  or  twice,  to  fix  the  bandage.  As  the  bandage  gradually  covers 
the  part,  each  turn  should  be  so  applied  as  to  overlie  that  just  below 
by  one-third  or  more  of  its  width ;  when  it  is  found  impossible  to  make 
the  bandage  lie  flat  on  the  limb,  owing  to  the  conical  shape  of  the  latter, 
the  roller  is  to  be  carried  off  obliquely,  the  bandage  fixed  on  the  limb 


134 


SURGICAL  TECHNIQUE 


by  the  thumb  or  finger  of  the  left  hand,  and  the  bandage  reversed 
(Fig.  82).  If  the  limb  is  conical  it  may  l)e  necessary  to  apply  the 
initial  extremity  of  the  bandage  obliquely  in  order  to  fix  it  without 
making  a  reverse.  When  the  part  has  been  completely  covered  in, 
the  end  of  the  bandage  may  be  fastened  with  a  pin  applied  trans- 
versely to  the  end  of  the  roller;  or  strips  of  adhesive  plaster  may  be 
used  instead.  The  point  of  the  pin  should  always  point  downward 
toward  the  distal  extremity  of  the  limb. 


Fig.  81. — Rolling  a  bandage  by  hand. 
(Wharton.) 


Fig.  82. — Method  of  making  reverses. 
(Wharton.) 


Fig.  83. — Method  of  removing  a  bandage.     (Wharton.) 


In  removing  a  bandage,  nothing  is  so  clumsy  and  time  consuming 
as  to  drag  the  end  around  and  around  the  limb  as  a  long  streamer. 
The  entire  bandage  should  be  bunched  up  and  passed  from  hand  to 


BANDAGING 


135 


hand  as  it  is  unwound  (I'l^-  83).  If  soiled,  it.  may  be  removed  by  band- 
age scissors  (Fig.  84),  the  blunt  end  easily  slii)]jiiig  between  the  folds 
of  bandage,  (^are  should  l)e  taken  not  to  cut  over  a  subcutaneous 
bone  (e.  g.,  the  shin),  and  always  to  keep  the  blades  at  right  angles  to 
the  surface  of  the  limb,  for  fear  of  ]))nehing  u})  the  skin  between  them. 
As  a  general  rule,  bandaging-  should  always  begin  below  and  i)roceed 
toward  the  trunk,  and  a  bandage  should  not  be  api)lied  to  a  limb 
without  co\'ering  in  the  entire  limb  from  fingers  or  toes  uj)  to  and 
beyond  the  diseased  part.  In  limbs  slightly  diseased,  swelling  of  the 
distal  part  may  not  always  follow  the  careful  a])pIication  of  a  bandage 
to  the  afi'ected  i)art  alone,  but  usually  the  whole  limb  is  more  or  less 
inflamed,  and  constricting  it  at  the  seat  of  greatest  swelling  may 
produce  marked  edema  of  the  distal  part  if  unsupported  by  the  band- 
age, and  cause  great  discomfort  to  the  })atient.  Tender  no  circum- 
stances should  a  bandage  })e  ai)plied  so  tightly  as  to  interfere  with 
the  circulation.  Hippocrates  taught,  and  it  is  still  absolutely  true, 
that  where  it  is  desired  to  give  pressure  to  a  part  by  means  of  bandages, 
it  is  much  safer  to  secure  this  by  employing  several  superimposed 
bandages  than  to  draw  the  primary  bandage  unduly  tight. 


Fig.  84. — Bandage  scissors. 


Gauze  bandages  are  much  emploj'ed  at  present;  but  they  are  inferior 
to  muslin  bandages  except  for  holding  dressings  lightly  in  place; 
they  are  of  most  use  for  the  head  and  neck,  because  they  are  so 
elastic  that  it  is  rarely  necessary  to  make  reverses.  But  if  drawn  at 
all  firmly  they  pull  into  strings  and  are  more  liable  than  muslin  to 
cause  injurious  constriction. 

Flannel  bandages  are  of  much  value  for  support  in  cases  of  edema, 
varicose  veins,  etc.  They  are  elastic,  especially  when  cut  on  the  bias, 
and  are  less  apt  to  irritate  the  skin  than  muslin  or  gauze.  Bandages 
of  elastic  webbing  are  used  for  the  same  purposes. 

Varieties  of  Bandages. — The  bandages  most  frequently  employed 
are  the  spiral  or  spiral  reversed  (Fig.  82),  which  is  universally  used 
in  the  extremities;  the  recurrent  (Fig.  85),  used  for  stumps,  the  head, 
etc.;  the  spica  (Fig.  86),  which  is  employed  to  cover  the  shoulder, 
groin,  buttock,  etc.;  figure-of-eight  bandages  (Figs.  87,  88  and  89),  used 
to  cover  joints,  to  draw  the  shoulders  backward  or  forward,  etc.; 
T-bandages  (Fig.  90),  for  holding  dressings  to  the  perineum;  the 
many-tailed  bandage,  or  bandage  of  Scultetus  (1655)  (Figs.  91  and  92), 
especially  useful  for  abdominal   wounds   or  other  cases  where  the 


136 


SURGICAL  TECHNIQUE 


patient  cannot  be  supported  while  a  roller  banday-e  is  applied.  The 
application  of  these  various  bandages  is  sulliciently  indicated  in  the 
accompanying  figures: 


f^/f  ,//'/'/  !:',^'^m/Ii. 


I'//  'I      '     ,  -- 


Fig.  85. — Recurrent  bandage. 
(Wharton.) 


Fig.  80. — Ascending  spica" bandage. 
(Wharton.) 


Fig.  87. — Figure-of-eight  bandage  of  the  Fig.  88.— Figure-of-eight    bandage    of 

knee.     (Wharton.)  the  neck  and  axilla.     (Wharton.) 


Fig.  89.— Posterior  figure-of-eight  bandage  of  the  chest'.     (Wharton.) 


HAND  AGING 


137 


Fixed  Dressings.  This  is  a  term  used  for  l)iiii(lii<,^('s  into  the  meshes 
of  which  some  sul)stauee  lias  been  incorporated  which  on  drying 
becomes  stiff.  The  materials  usu- 
ally emj)l()yed  are  starch,  silicate  of 
sodium,  or  i)laster  of  Paris,  espe- 
cially the  last.  The  bandage  itself 
is  made  of  crinoline  or  coarse 
meshed  gauze. 

Plaster  of  Paris.-Tliis  powder  is 
hygrosco])ic;  when  moistened  and 
allowed  to  dry  it  is  converted  into 
gypsum,  the  process  })cing  known 
as  scU'uuj.  It  is  worked  into  the 
meshes  of  the  bandage  by  a  spatula; 
the  bandage  is  then  loosely  rolled, 
tied  in  waxed  paper,  and  put  away 
in  an  air-tight  box  until  wanted. 
These  bandages  may  be  kept  thus 
for  several  weeks,  but  are  always 
better  when  freshly  made.  When 
it  is  desired  to  use  them,  one  band- 
age is  placed  on  end  in  hot  water 
which  completely  covers  it,  and  is 
until  bubbles  cease  to  rise. 


Fig.  90. — Double  tailed,  or  T-handage. 

allow'ed  to  remain  in  the  water 
The  bandage  is  then  removed  from  the 


Fig.  91. — Bandage  of  Scultetus  (many  tailed). 


Fig.  92. — Scultetus  bandage  applied;  overlapping  turns  fastened  with  safety- 
pins.     Episcopal  Hospital. 

water,  is  grasped  by  its  two  ends  in  the  hands,  and  is  squeezed  as  dry 
as  possible.    It  is  then  applied  as  an  ordinary  roller  bandage  to  the 


138 


SURGICAL  TECHNIQUE 


part  (Fig.  93),  which  must  have  been  previously  protected  by  one  or 
two  layers  of  flannel  bandage  or  of  cotton  batting;  bony  ])rominences 
should  be  additionally  protected  by  raw  cotton  or  felt  pads.  A  suffi- 
cient number  of  ])laster  bandages  should  be  applied  to  render  the 


Fig.  93. — Plaster-of-Paris  bandage  being  applied  to  leg.    The  foot  should  be 
kept  at  a  right  angle  with  the  leg.     Orthopsedic  Ho.spital. 

bandage  firm  when  it  has  set.  Usuall}'  four  to  six  are  required  for  the 
foot  and  leg,  eight  to  ten  for  the  knee,  and  twelve  or  more  for  the  pelvis 
or  trunk.  The  bandages  should  be  placed  in  the  water  only  as  needed ; 
they  set  quickly,  and  prompt  action  and  skilful  work  are  required  to 
make  a  satisfactory  gypsum  case,  or  "cast"  as  it  is  popularly  called. 


Fig.  94. — Removing  gypsum  case  by  means  of  Hunter's  saw.     Orthoi  aedic  Hospital. 

Before  the  last  bandage  is  applied,  the  projecting  margins  of  the 
underlying  flannel  bandage  may  be  turned  down  over  the  ends  of  the 
cast,  and  be  held  in  place  by  a  few  turns  of  the  last  bandage :  this  covers 
in  the  rough  edges  of  the  cast,  which  unless  co^'ered  cause  great 


ANTISEPSIS  AND  ASEPSIS 


139 


annoyance  to  tlie  patient.  Finally  some  "plaster  eream"  may  be  rul)bed 
all  over  the  .surface  of  the  last  handaj^a-:  tiiis  is  made  hy  adding  just 
enough  water  to  a  couple  of  handfuls  of  plaster  to  make  a  thick  paste. 
This  refinement  not  only  improves  the  appearance  of  the  cast,  hut  hy 
giving  it  a  glazed  surface  (enhanced  by  wiping  with  gauze  moistened 
in  alcohol)  keeps  the  cast  clean  much  longer,  "^riie  gyj)sum  usually 
is  (juite  firm  enough  in  half  an  hour  for  the  i)atient  to  be  mo\ed  easil}'. 
Starch.^ — Starch  is  applied  in  the  form  of  a  paste,  by  rubbing  it  into 
the  bandages  as  they  are  applied.  It  is  much  more  brittle  and  liable 
to  break  than  gypsum,  but  may  be  used  as  a  top  dressing  to  a  soiled 
cast  which  it  is  undesirable  to  remove. 


Fig.  95. — Gj^psum  dressing  trapped.     Orthopaedic  Hospital. 

Silicate  of  Sodium. — Silicate  of  sodium  is  a  pale  yellow  liquid  of  the 
consistency  of  mucilage.  It  is  best  applied  to  the  bandages  by  rolling 
them  on  a  winch  in  a  trough  full  of  the  liquid,  as  in  the  apparatus  of 
G.  G.  Davis.  Silicate  makes  a  light,  ornamental  cast,  possessing  all 
the  good  qualities  of  the  gypsum,  except  that  at  least  thirty-six  hours 
are  required  for  it  to  harden  completely.  It  is  much  cleaner  than 
plaster  of  Paris  and  is  readily  soluble  in  water. 

These  fixed  dressings  are  best  removed,  I  think,  by  the  use  of 
Hunter's  saw^  (Fig.  94);  when  the  gypsum  is  cut  to  the  underlying 
bandage,  a  fact  easily  detected  by  the  sensation  imparted  to  the  hand 
by  the  saw,  the  remaining  bandages,  and  any  part  of  the  cast  too 
soft  to  be  cut  by  the  saw,  may  be  cut  by  a  stout  pair  of  bandage 
scissors.  When  desirable,  a  cast  so  removed  may  be  sprung  oflf  and 
reapplied,  being  held  together  by  adhesive  straps  or  bandages.  The 
gypsum  may  be  cut  away  at  any  time  (most  easily  while  still  setting) 
to  make  a  "window"  or  "trap"  through  which  a  wound  may  be 
dressed  (Fig.  95). 


ANTISEPSIS  AND  ASEPSIS. 

In  order  to  prevent  entrance  of  microorganisms  into  wounds  at 
operation  or  other  times,  it  is  absolutely  necessary  to  take  such  pre- 
cautions as  will  kill  all  bacteria  which  might  be  introduced  through 
the  medium  of  instruments,  dressings,  or  the  hands  of  surgeons, 
assistants,  or  nurses;  or  from  the  skin  of  the  patient  himself,  or 
from  septic  structures  within  his  body  invaded  during  the  course  of 


140  SURGICAL  TECHNIQUE 

operation.  A  thing  is  sterile  when  there  are  no  bacteria  on  it,  or  when 
all  the  bacteria  on  it  are  dead.  Everything  that  has  not  been  sterilized 
is  considered  in  surgery  to  he  seidic.  It  is  next  to  impossil)le  to  remove 
bacteria,  and  entirely  impossible  to  know  clinically  whether  all  the 
bacteria  have  been  removed  or  not.  The  only  recourse,  therefore, 
is  to  kill  them  all.  This  is  most  readily  accomplished  by  the  use  of 
moist  heat  (boiling),  as  no  bacteria  can  survive  a  temperature  of  over 
100°  C.  for  more  than  ten  to  fifteen  minutes.  Everything  that  can  be 
boiled  may  therefore  be  sterilized  in  this  way,  and  must  not  again 
be  touched  by  anything  septic;  if  it  is,  it  must  be  re-sterilized  before 
it  can  be  used  safely.  Instruments,  basins,  buckets,  etc.,  are  readily 
sterilized  by  boiling.  Enough  sodium  carbonate  (washing  soda) 
should  be  placed  in  the  water  to  prevent  oxidation  (rusting)  of  the 
instruments  (tablespoonful  to  a  quart).  Dressings  may  be  treated 
in  the  same  way,  but  as  they  take  much  longer  than  instruments  to 
cool  off,  and  are  nearly  useless  when  wet,  it  is  much  more  satisfactory 
to  sterilize  such  things  in  a  steam  autoclave.  For  this  purpose  they 
are  loosely  wrapped  in  an  outer  covering,  which  is  undone  after  they 
have  been  sterilized,  and  the  contents  of  the  package  are  removed 
only  by  sterile  hands  or  instruments  at  the  time  of  operation.  If 
carefully  wrapped  and  kept  so,  such  dressings  may  be  preserved  in  a 
sterile  state  for  several  days  at  a  time;  though  it  is  always  safer  to 
re-sterilize  them  on  the  day  of  the  operation.  As  the  temper  of  knives 
is  readily  spoiled  by  boiling,  and  as  their  surfaces  are  smooth  and 
therefore  readily  cleansed  mechanically,  I  think  it  is  best  to  use 
chemicals  to  sterilize  them;  placing  them  for  twenty  minutes  in  hot^ 
carbolic  acid  solution  (5  per  cent.)  and  then  in  alcohol  (70  per  cent.) 
until  used. 

The  hands  of  the  surgeon  and  his  assistants,  and  the  skin  of  the 
patient,  however,  cannot  be  sterilized  by  heat;  they  must  be  prepared 
by  mechanical  and  chemical  processes.  (When  a  surgeon  speaks  of 
his  hands,  he  should  use  the  term  in  the  sense  of  the  Greek  word  '/J^l>, 
which  meant  the  hands  and  forearms  up  to  and  including  the  elbows.) 
The  hands  are  best  prepared  by  washing  in  hot  soapsuds,  with  careful 
use  of  a  nail-brush,  for  ten  minutes;  then  the  soap  is  rinsed  off,  and 
further  removed  by  soaking  the  hands  and  forearms  in  alcohol;  finally 
they  are  soaked  in  a  hot  solution  of  bichloride  of  mercury  (1  to  2000) 
or  of  carbolic  acid  (2.5  per  cent.).  The  patient's  skin  is  prepared  in 
the  same  way,  and  is  covered  with  sterile  gauze  until  the  time  of 
operation.  The  mechanical  cleansing  with  the  nail-brush,  aided  by  the 
macerating  efi'ect  of  heat,  and  soapsuds,  removes  all  loose  epithelium 
and  probably  removes  almost  all  the  germs  present.  The  alcohol 
by  its  dehydrating  effects  opens  up  the  orifices  of  the  cutaneous  glands 
and  allows  the  antiseptic  subsequently  used  to  penetrate  the  skin 
more  effectively,  thus  weakening,  if  not  killing,  the  germs  always 
present  in  the  deeper  layers.    IVIost  surgeons  in  this  country  prefer  to 

1  It  is  worth  noting  in  this  place  that  all  antiseptic  solutions  are  much  more 
efficient  when  hot  than  if  cold  or  merely  luke-warm. 


AX  T  J  SEPSIS  AND  ASEI'SIS  141 

wear  ()\tT  tlit'ir  hands  tliiii  ruhhcr  gloves  wliicli  have  been  properly 
sterili/.fd.  Tliere  is  no  douht  to  my  iiiiiid  that  they  are  a  most  val- 
uable addition  to  the  surj^ical  armamentarium,  chiefly  as  a  jirotection 
to  the  sur<:;et)n  from  contamination  in  septic  cases.  The  use  of  fi;love.s 
in  no  way  absolves  the  surj>;eon  from  careful  ])rei)aration  of  his  hands, 
l)ut  it  enables  him  in  emeru'cncy  to  pass  from  a  septic  tt)  an  aseptic 
oi)eration  with  an  imi)unity  which  can  never  be  enjoyed  when  he 
operates  with  bare  hands.  All  ])ersons  concerned  in  the  operation 
wear  sterile  gowns,  and  caps,  and  the  operators  wear  face  masks  of 
gauze  to  ])revent  contamination  of  the  wound  or  the  instruments  or 
dressings  in  any  concei\"able  manner. 

lodin  Disinfection. — (irossich  in  1908  found  if  the  patient's  skin 
(without  previous  preparation  except  dry  shaving)  were  painted  with 
a  10  to  12  per  cent,  alcoholic  solution  of  iodin  shortly  before  operation, 
at  the  time  of  operation,  and  at  the  close  of  the  operation,  the  woimds 
healed  better  than  after  the  habitual  methods  of  skin  prej)aration. 
This  method  is  poi)ular  for  its  simplicity  and  efficiency,  and  is  now  in 
general  use.  ]\Iost  surgeons  find  an  alcoholic  solution  of  from  3  to  5 
per  cent,  strong  enough,  but  many  do  not  sufficiently  appreciate  the 
fact  that  the  skin  must  be  dry,  if  the  iodin  is  to  be  of  any  use.  It 
must  not  have  l)een  wet  for  three  or  four  hours  at  least. 

Antiseptic  methods  of  operating  wTre  introduced  before  aseptic 
methods  (Lister,  18G5;  Lucas-Championniere,  1869,  1876),  and  are 
still  most  widely  applicable.  Here,  after  preparing  the  dressings, 
instruments,  and  skin  as  above,  the  surgeon  keeps  his  instruments  in 
antiseptic  solutions  (2.5  per  cent,  carbolic  acid);  uses  sponges  soaked 
in  antiseptics  for  mopping  out  the  wound;  and  at  the  conclusion  of 
the  operation  applies  a  stronger  antiseptic  solution  (5  per  cent,  carbolic 
acid,  5  or  10  per  cent,  zinc  chloride,  1  to  1000  corrosive  sublimate,  etc.) 
to  the  entire  surface  of  the  wound.  In  this  way  he  makes  sure  that 
any  microorganisms  introduced  into  the  w^ound,  accidentally,  will 
have  an  unfavorable  soil  for  growth,  and  that  in  all  probability  they 
will  be  so  weakened  by  the  antiseptics  employed  as  easily  to  be  killed 
by  the  tissues  of  the  body.  This  method  of  operating  is  applicable 
to  all  primarily  septic  conditions  (compound  fractures,  necrosis, 
abscesses,  malignant  tumors,  most  amputations,  etc.),  and  is  valuable 
in  a  somewhat  modified  form  in  all  operations  where  the  tissues  are 
much  })ruised  or  long  exposed  to  the  atmosphere  during  the  course 
of  the  operation  (some  excisions,  ununited  fractures,  tedious  dissec- 
tions, etc.).  When,  however,  the  operation  is  of  short  duration  (under 
half  an  hour),  or  when  the  tissues,  even  during  a  longer  operation, 
are  not  bruised  or  otherwise  unduly  injured,  and  especially  in  visceral 
surgery,  the  aseptic  method  is  superior. 

Aseptic  methods  of  operation  have  been  in  general  use  only  for  the 
last  ten  or  fifteen  years,  and  were  systematized  largely  by  Terrier  and 
his  pupils.  The  instruments,  dressings,  etc.,  are  sterilized,  and  the 
instruments  are  placed  in  sterile  water  or  laid  on  a  table  covered  with 
sterile  sheets.    The  hands  and  the  patient's  skin  are  prepared  in  the 


142  SURGICAL  TECHNIQUE 

usual  way,  but  no  antiseptics  whatever  are  used  during  the  course  of 
the  operation;  everything  coming  into  contact  with  the  wound  is 
sterile;  and  it  depends  on  the  unceasing  and  seemingly  pedantic  pre- 
cautions of  the  surgeon  to  keej)  the  wound  aseptic.  If  one  mis-step 
is  made,  the  aseptic  has  to  be  abandoned  for  the  antiseptic  method; 
and  while  I  think  the  surgeon  should  always  employ  the  aseptic  method 
when  he  safely  can,  because  antiseptics  are  at  times  harmful  to  the 
patient,  and  occasionally  delay  the  process  of  repair,  yet  it  cannot  be 
denied  that  adherence  to  a  strictly  aseptic  technique  is  much  more 
difficult;  and  it  must  be  acknowledged  that  many  surgeons  seem  incap- 
able of  practising  it  thoroughly.  When  either  method  is  properly 
employed,  the  wound  heals  without  noticeable  inflammatory  reaction, 
no  stitch  abscesses  form,  no  discharging  sinuses  remain,  no  ligatures 
are  slowly  eliminated  from  its  depths,  no  granulations  persist  at  one 
end  of  the  incision,  the  comfort  of  the  patient  is  enhanced,  and  the 
after-treatment  much  simplified. 

MINOR  SURGERY. 

Counter-irritation. — Counter-irritation  is  conveniently  secured  by 
the  use  of  very  hot  compresses,  by  turpentine  stupes,  or  by  means 
of  plasters  of  mustard,  capsicum,  etc.  While  these  remedies  are 
merely  rubefacient  in  their  effect,  cantharides  plaster  will  produce  a 
blister  (vesication);  the  surface  of  the  plaster  should  be  wiped  with 
olive  oil  or  petrolatum,  so  as  to  prevent  it  sticking  to  the  cuticle. 
It  should  be  removed  in  six  or  eight  hours,  and  the  blister  will  com- 
monly draw  for  several  hours  more;  meanwhile  it  should  be  dressed 
lightly  with  an  ointment,  and  when  fully  drawn  the  tense  cuticle 
should  be  punctured  with  an  aseptic  bistoury,  and  allowed  to  collapse 
on  to  the  face  of  the  blister  as  the  serum  exudes.  When  the  blister 
shows  a  tendency  to  dry  up,  this  may  be  encouraged  by  applying  talc 
or  other  dusting  powder.  Canterization  is  readily  secured  by  means 
of  the  Paquelin  cautery,  in  which  the  platinum  cautery  point  is  first 
brought  to  a  red  heat  in  an  alcohol  flame,  and  is  then  kept  incandescent 
by  exposing  it  to  the  vapor  of  benzole  or  rhigolene,  which  is  pumped 
along  the  hollow  handle  of  the  cautery  iron,  from  the  receptacle  w^here 
it  is  contained,  by  means  of  a  hand  bulb.  To  produce  vesication  or 
still  slighter  degrees  of  counter-irritation,  it  is  sufficient  merely  to 
touch  the  skin  with  the  cautery  iron  when  at  a  cherry  red  heat,  or 
even  to  hold  it  close  to  the  skin  without  bringing  the  iron  into  actual 
contact  w^ith  it.  In  certain  operations  the  actual  cautery  is  of  the 
utmost  value  in  checking  the  oozing  of  blood  or  destroying  the  fungous 
granulations  of  inoperable  tumors.  The  wound  left  is  rendered  aseptic 
by  the  heat,  and  will  usually  heal  without  suppuration.  Whenever 
using  the  actual  cautery,  the  highly  inflammable  quality  of  ether  must 
be  remembered. 

Acupuncture. — Acupuncture  is  a  little  operation  sometimes  used 
in  cases  of  lumbago,  etc.    After  preparing  the  patient's  skin  as  for  an 


MINOR  SURGERY  143 

operation,  six  to  ten  sterile  needles  (ordinary  hat  pins  will  do)  are 
tlirust  intt)  the  k)ins  with  a  quiek  })oring  motion,  and  are  allowed  to 
remain  in  i)laee  a  few  minntes.  Care,  of  course,  must  be  exercised  not 
to  injure  any  superficial  vein,  nerve,  etc.,  and  not  to  enter  the  spinal 
canal.    No  anesthetic  is  required. 

Vaccination. — Vaccination,  though  usually  done  by  the  family 
I)hysi(i;in,  is  a  surgical  procedure.  The  method  I  prefer  is  the  follow- 
ing :'the  skin  of  the  arm  is  rubbed  briskly  with  an  alcohol  sponge,  and 
vigorously  dried  with  sterile  gauze;  this  arouses  the  circulation  of  the 
part,  and  makes  the  virus  more  apt  to  "  take."  Then  with  the  belly  of 
an  asej)tic  and  rather  dull  scalpel  the  cuticle  is  scraped  ofl'  over  an  area 
about  s  inch  (1  cm.)  square  until  the  surface  is  moist.  No  blood  should 
be  drawn.  The  vaccine  is  then  quickly  applied,  and  rubbed  into  the 
abraded  area  by  means  of  the  ivory  point  or  glass  tube  in  which  it  is 
supplied.  The  vaccinated  area  is  allowed  to  dry,  conqjletely ,  in  the 
air,  and  no  shield  or  bandage  is  em])loyed.  In  a  continuous  series  of 
several  hundred  vaccinations  by  this  method,  when  house  surgeon 
at  the  Episcopal  Hospital,  I  failed  to  secure  a  "take"  at  the  first 
attempt,  in  only  two  or  three  previously  un^■accinated  patients.  The 
wound  should  be  painted  daily  with  a  8  per  cent,  solution  of  iodin. 

Hypodermic  Injections. — Convenient  tablets  containing  the  requi- 
site amount  of  the  drug  are  easily  obtained  from  manufacturers. 
The  tablet  is  dissolved  in  a  half  dram  of  sterile  water  or  saline  solu- 
tion, or  the  water  with  the  tal)let  in  it  may  be  sterilized  in  a  spoon 
over  a  flame.  The  fluid  is  then  drawn  up  into  the  barrel  of  the  hypo- 
dermic syringe  previously  sterilized  by  boiling  or  by  soaking  in  an 
antiseptic  solution  (which  should  of  course  have  been  removed  by 
rinsing  the  interior  of  the  syringe  in  sterile  water).  The  sterilized 
hollow  needle  is  then  screwed  on  to  the  nozzle  of  the  syringe,  and 
any  bubbles  of  air  are  expelled  by  driving  the  piston  home,  while  the 
needle  is  held  upward,  until  the  fluid  spurts.  Then  a  fold  of  the 
patient's  skin,  prepared  by  vigorous  rubbing  with  an  alcohol  sponge, 
is  picked  up  between  the  thumb  and  finger  of  the  left  hand,  and  the 
needle  quickly  thrust  obliquely  into  this  fold,  so  that  the  point  enters 
the  subcutaneous  tissues.  Care  must  be  taken  to  avoid  entering  a 
subcutaneous  vein,  wounding  a  nerve,  etc.  The  best  situations  for 
hypodermic  injections  are  over  the  deltoid  muscle,  on  the  outer 
surface  of  the  thigh  or  calf,  in  the  buttocks,  the  loins,  or  the  lateral 
abdominal  wall.     No  dressing  is  required  for  the  needle  puncture. 

Use  of  Saline  Solution. — The  object  of  this  solution  is  to  supply 
a  fluid  as  nearly  like  the  blood  as  possible.  The  following  formula  is 
recommended  by  Park: 

I^ — Calcium  chloride,  2  parts 

Potassium  chloride,  3  parts 

Sodium  chloride,  9  parts 

Sterile  water,  1000  parts 

This  should  be  prepared  aseptically  and  should  again  be  sterilized 
before  use.     In  emergencies  it  is  sufficient  to  add  a  teaspoonful  of 


144  SURGICAL  TECHNIQUE 

sodium  chloride  (table  salt)  to  each  pint  of  water,  boiling  the  solution 
before  using.  This  fluid  is  used  hypodermically  (hypodermoclysis), 
by  the  bowel  {yrodoclysis) ,  and  by  intravenous  infusion.  It  is  also 
widely  employed,  especially  in  abdominal  surgery,  as  a  substitute  for 
sterile  water.  It  should  be  injected  at  a  temperature  of  from  110° 
to  115°  F.  For  hypodermoclysis,  proctoclysis,  or  intravenous  use, 
it  is  convenient  to  let  it  flow  out  of  a  glass  jar  graduated  from  above 
downward,  so  that  a  glance  will  show  how  much  has  been  given. 
In  emergencies,  a  sterile  fountain  syringe  or  funnel  will  answer  the 
purpose.  The  main  purposes  for  which  it  is  used  are  to  combat  hem- 
orrhage and  shock  by  restoring  blood  pressure  (p.  175),  and  to  dilute 
toxins  circulating  in  the  blood. 

Hypodermoclysis.^ — This  is  the  subcutaneous  instillation  of  saline 
solution.  A  long  hollow  needle,  with  large  calibre,  is  used ;  it  is  attached 
to  a  rubber  tube  connecting  with  the  receptacle,  which  may  be  several 
feet  higher  than  the  patient.  The  clip  on  the  tube  is  released,  and, 
while  the  fluid  is  running  from  the  needle,  this  is  thrust  into  the  sub- 
cutaneous tissues  as  in  administering  a  hypodermic  injection.  The 
best  sites  for  hypodermoclysis  are  under  the  mammary  glands,  over 
the  lower  border  of  the  pectoralis  major;  in  the  flanks,  the  lateral 
abdominal  walls,  or  between  the  scapulae.  From  eight  to  ten  ounces 
may  be  introduced  through  one  puncture,  the  accumulating  fluid 
being  gently  rubbed  out  into  the  tissues.  Rarely  more  than  one 
quart  is  required  by  hypodermoclysis.  The  fluid  is  not  absorbed  very 
rapidly,  and  where  immediate  effect  is  desired  it  should  be  given 
intravenously.  The  needle  punctures  should  be  painted  with  collo- 
dion and  sealed  with  a  scab  of  absorbent  cotton.  Under  the  term 
axillary  infusion  has  been  described  a  method  of  hypodermoclysis  by 
which  absorption  is  very  rapid:  a  puncture  is  made,  with  a  bistoury, 
through  the  skin  over  the  pectoralis  major  muscle  about  midway 
between  the  clavicle  and  anterior  axillary  fold;  then,  with  the  fingers 
of  the  left  hand  in  the  armpit  as  a  guide,  the  hypodermoclysis  needle 
(not  dangerous  because  blunt)  is  thrust  through  this  puncture  into 
the  cellular  tissues  of  the  axilla,  traversing  the  pectoral  muscle;  the 
solution  is  then  allowed  to  flow. 

Proctoclysis. — Proctoclysis,  the  rectal  instillation  of  saline  solution,^ 
is  widely  employed  in  the  treatment  of  peritonitis  (Murphy,  1905). 
A  soft  rubber  catheter  is  attached  to  the  rubber  tube  leading  from  the 
reservoir,  which  should  not  be  more  than  a  few  inches  higher  than  the 
patient's  buttocks;  the  eye  of  the  catheter  is  placed  just  within  the 
anus.  The  solution  should  flow  into  the  rectum  very  slowly,  about 
a  pint  and  a  half  every  forty  to  sixty  minutes  for  an  adult.  If  a  pint 
and  a  half  of  the  solution  are  placed  in  the  reservoir  every  two  hours, 
eighteen  pints  will  be  absorbed  in  a  day,  and  the  rectum  will  have 
periods  of  rest  of  an  hour  or  more  after  each  amount  has  been  absorbed. 
The  catheter  is  to  remain  in  place  continuously.    This  treatment,  may 

1  Sterile  water,  without  the  addition  of  salines,  is  just  as  efficient;  it  is  not 
irritating  to  the  bowel  and  is  absorbed  as  readily  (Trout,  1912). 


MIXOli  SURIJEHY  145 

1)0  coiitiiiiKMl  Tor  four  or  five  days  if  necessary.  If  too  inueli  fluid  is 
administered,  slight  edema  of  the  ankles,  hands,  and  even  face  may 
appear  (Murphy).  The  sohition  is  j)hieed  in  the  container  hot  (105° 
to  110°  F.),  and  may  he  kept  hot  by  hot  water  hags  (Fig.  805);  but  it 
is  probable  that  owing  to  its  slow  flow,  it  is  about  the  temperature  of 
the  blood  or  lower  after  traversing  the  tube  to  the  ])atient. 

Intravenous  Infusion.  The  patient  often  is  so  shocked  that  no 
anesthetic  is  required.  A  blunt  pointed  cannula  is  used,  the  eye  being 
bevelled  to  facilitate  its  introduction  into  the  vein.  Select  a  super- 
ficial vein  (usually  the  median  cephalic  at  the  elbow),  and  tie  a  tight 
bandage  around  the  extremity  on  the  cardiac  side  of  the  vein  selected, 
in  order  to  render  it  visible  and  fully  disteniled.  Prepare  the  skin 
and  your  hands  in  the  usual  way.  Then  make  an  incision  somewhat 
obli(|uely  to  the  course  of  the  vein,  about  an  inch  long,  and  cut  down 
with  light  strokes  directly  on  to  the  vein,  which  may  be  embedded  in 
fat.  Do  not  tease  and  maul  the  fat;  this  favors  infection  of  any 
wound.  When  the  vein  is  thoroughly  exposed  in  this  way,  thrust  a 
grooved  director  across  beneath  the  vein,  and  along  the  groove  slip 
two  ligatures.  Draw  one  of  the  ligatures  to  the  distal  side  of  the 
grooved  director  and  ligate  the  vein;  draw  the  other  ligature  upward, 
on  the  cardiac  side  of  the  director,  and  loop  it  but  do  not  tie  it  tight. 
Then  pass  a  sharp  scissors  along  the  grooved  director,  and,  controlling 
the  blood  by  a  finger  of  the  other  hand  on  the  cardiac  side  of  the 
director,  cut  the  vein  half  way  across  (Fig.  96).  Lay  aside  the  scissors, 
and  take  the  infusion  cannula  in  the  right  hand,  have  the  clip  removed 
from  the  tube,  and,  while  the  saline  solution  is  running  from  the 
cannula,  gently  insert  this  into  the  gaping  wound  in  the  vein,  point- 
ing it  toward  the  heart,  and  tie  the  ligature  already  placed  so  as  to 
secure  the  cannula  in  the  vein.  Then  withdraw  the  grooved  director 
and  have  the  bandage  around  the  limb  cut,  so  as  to  allow  the  venous 
current  to  flow.  The  reservoir  should  not  be  held  more  than  a  foot 
or  two  above  the  patient's  body,  and  the  saline  sohition  should  not 
flow  more  rapidly  than  a  pint  in  ten  minutes.  The  amount  introduced 
must  depend  on  the  state  of  the  patient's  pulse.  Usually  a  quart  is 
more  than  enough:  occasionally  several  quarts  will  be  required. 

Direct  Transfusion. — This  operation,  introduced  by  Crile  (1906), 
implies  the  transference  of  blood  directly  from  an  artery  of  a  healthy 
person  (known  as  the  donor)  to  a  vein  of  the  patient  (the  recipient). 
It  has  entirely  superseded  indirect  transfusion,  a  method  in  which 
blood  was  first  drawn  into  a  receptacle,  then  defibrinated,  and  finally 
injected  into  the  patient's  veins.  For  the  operation  of  direct  trans- 
fusion local  anesthesia  (cocain)  should  be  used.  Crile's  technique 
requires  few  special  instruments  beyond  the  silver  cannula  (Fig.  97) ; 
hyi)odermic  syringes  and  0.1  per  cent,  cocain  solution  (Formula  A,  p. 
156);  scalpel,  scissors,  two  rubber-covered  artery  clamps  (Nunneley's 
clips  do  very  well),  six  fine  bladed  ("mosquito")  hemostats,  linen  or 
silk  ligatures;  as  well  as  needles  and  suture  material  for  closing  the 
skin  wound. 
10 


146 


SURGICAL   TECHNIQUE 


Give  })oth  donor  and  patient  a  hypodermic  injection  of  morphin 
half  an  hour  before  the  operation.  Place  the  donor  horizontally  on 
an  operating  table  so  arranged  that  its  head  may  be  lowered  if  the 


Fig.  96. — Intravenous  infusion  of  saline  solution. 

donor  faints.  Place  the  recipient  on  another  table  with  his  head 
toward  the  donor's  feet.  Use  cocain  locally  (0.1  per  cent,  solntion). 
Expose  first  3  cm.  of  the  radial  artery  of  donor,  ligate  distal  and 
clamp  proximal  end.    Divide  close  to  the  ligature.    By  squeezing  with 


Fig.  97. — Direct  transfusion  of  blood  by  moans  of  Crile's  cannula.  In  the  upper 
illustration  the  vein  is  being  drawn  through  the  cannula  by  a  sharp  hook.  In  the  lower, 
the  end  of  the  vein  has  been  everted  and  tied  to  the  cannula,  and  the  arterj^  is  about 
to  be  drawn  over  the  vein. 

fingers  on  the  free  (proximal)  end  of  the  artery,  the  adventitia  is 
made  to  project  beyond  the  inner  coats,  and  is  cut  off  with  scissors. 
As  the  adventitia  retracts,  the  muscular  and  endothelial  coats  are  left 


MINOR  SURGERY  147 

projcctinj;.  Cover  tlie  artery  with  gauze  wet  in  liot  saline  solution. 
Expose  W  to  4  cm.  of  a  large  superficial  vein  of  the  recipient,  ligate  the 
distal  and  damp  the  proximal  end;  divide  close  to  the  ligature,  and 
remove  the  adventitia  as  above  described.  Pass  the  vein  through  the 
cannula,  which  is  held  by  a  hemostat;  I  have  found  it  easier  to  draw 
it  through  with  a  fine  hook  (Fig.  97).  P^vert  the  walls  of  the  vein  by 
aid  of  mosquito  hemostats,  and  ligate  with  linen  or  silk  the  everted 
vein  in  the  groove  next  the  handle  of  the  cannula.  Then  with  the  aid 
of  three  mosquito  hemostats,  draw  the  artery  over  the  end  of  the 
vein,  and  ligate  it  around  the  other  groove  in  the  cannula.  Unclamp 
the  vein;  then  unclamp  the  artery,  and  let  the  blood  flow  slowly. 
The  amount  to  be  transfused  depends  on  the  reaction  of  both  donor 
and  recipient.  It  is  best  to  stop  the  flow  so  soon  as  the  donor  begins 
to  sigh,  indicating  respiratory  embarrassment  from  the  loss  of  blood. 
Of  course,  if  the  recipient  is  brought  to  a  satisfactory  state  by  a  less 
amount  of  blood,  less  will  suffice.  It  is  truly  astonishing  to  see  the 
color  return  to  blanched  lips,  the  lustre  to  the  eyes,  and  to  behold  the 
general  hienseance  which  is  produced  by  direct  transfusion.^ 

Phlebotomy. — Phlebotomy  which  is  usually  preferred  to  arteriotomy 
for  "letting  blood,"  is  generally  done  in  the  median  cephalic  or  median 
basilic  vein.  The  vein  is  made  tense  by  applying  a  tight  bandage 
above  it,  the  skin  is  properly  prepared,  and  a  small  incision  (1  cm.) 
is  made  directly  over  and  into  the  vein.  No  anesthetic  is  required. 
The  spurting  blood  is  caught  in  a  suitable  basin;  it  may  be  made 
to  run  more  freely  by  having  the  arm  dependent  or  by  directing  the 
patient  to  work  his  fingers  around  a  bar,  alternately  tightening  and 
loosening  his  grip.  The  patient  should  be  in  a  sitting  posture,  so  that 
any  faintness  may  be  quickly  perceived.  It  is  seldom  desirable  to 
draw  more  than  a  pint.  The  wound  is  dressed  with  a  pledget  of 
sterile  gauze,  no  suture  being  required;  and  the  same  wound  may 
easily  be  reopened  for  further  bleeding  during  the  next  few^  days. 

Leeching. — The  Swedish  leech,  which  is  preferred,  draws  from 
three  to  four  drams  of  blood.  The  skin  is  carefully  washed,  and  the 
leech  applied  over  the  part  to  be  leeched,  but  not  directly  over  a  super- 
ficial vein.  If  the  leech  does  not  bite,  a  little  milk  or  blood  should  be 
placed  on  the  skin.  When  he  has  drunk  his  fill  he  will  fall  oft";  or  this 
may  be  hastened  by  applying  salt  over  the  leech  and  neighboring  skin. 
The  blood  usually  continues  to  flow  for  some  time,  so  that  a  much 
larger  quantity  may  be  drawn  from  one  leech  bite  than  the  capacity  of 
the  leech.  When  enough  has  been  drawn,  the  bite  should  be  dressed 
antiseptically,  and  moderate  pressure  applied. 

Aspiration. — By  means  of  a  vacuum  bottle  it  is  easy  to  withdraw 
fluid  collections  through  a  hollow  needle.  The  bottle  is  first  emptied 
of^air  as  far  as  possible  by  the  suction  pump;  the  valves  are  then  turned, 

'  Several  types  of  tubes  (glass  or  metal,  to  be  lined  with  paraffin  before  using) 
are  now  on  the  market,  by  which  it  is  thought  the  operation  of  direct  transfusion 
is  rendered  easier  than  by  Crile's  original  technique;  but  I  have  had  no  personal 
experience  with  them.     Those  of  Brewer  and  of  Bernheim  are  most  popular. 


148 


SURGICAL   TECHNIQUE 


and,  the  skin  having  been  j)roperly  ])repare(l,  the  sterile  trocar  and 
cannula  are  thrust  through  the  overlying  tissues  into  the  collection 
of  fluid  (hydrothorax,  empyema,  cold  abscess,  etc.)-  The  trocar  is 
then  withdrawn,  the  valve  turned  to  close  its  passage,  and  the  valve 
leading  from  the  cannula  to  the  bottle  is  opened,  allowing  the  fluid 
to  flow  (Fig.  98).  If  the  lumen  of  the  cannula  is  blocked  by  flakes  of 
lymph,  a  stylet  may  be  passed  through  it  from  time  to  time.  The 
puncture  sliould  1  c  dressed  antiseptically. 


Fig.  98. — Asjiiration  of  a  luml>Mi 


isrn],a]  Hospital 


ANESTHESIA  AND  ANESTHETICS. 

Certain  gases,  which  are  respirable,  induce  unconsciousness  when 
absorbed  through  the  lungs  and  carried  to  the  nerve  centres.  The 
state  so  produced  is  called  general  anesthesia.  In  addition  to  uncon- 
sciousness, which  implies  analgesia  and  anesthesia,  muscular  relaxa- 
tion is  also  produced.^  It  is  possible  to  secure  the  same  effects  from 
some  such  drugs  when  administered  otherwise  than  by  inhalation,  as 
by  rectal  administration;  but,  as  a  rule,  general  anesthesia  is  secured 
by  inhalation  of  the  vapor  of  ether,  chloroform,  ethyl  chloride,  etc. 
Local  anesthesia  is  produced  by  the  local  use  of  some  drug,  usually 
introduced  by  hypodermic  injection,  which  acts  on  the  peripheral 
ner^'es;  cocain  and  eucain  are  most  used  for  this  purpose. 

General  Anesthesia. — The  patient  should  have  his  bowels  well 
opened  the  day  previously,  and  should  have  eaten  no  food  for  at  least 
eight  hours  befor  the  anesthetic  is  administered,  as  all  general  anes- 
thetics, especially  ether,  produce  some  degree  of  nausea.  In  opera- 
tions not  involving  the  stomach  or  intestines,  there  is  no  objection 
to  the  patient  drinking  a  glass  of  hot  water  half  an  hour  before  the 
operation.  This  prevents  gastric  irritation  from  any  of  the  anesthetic 
unavoidably  swallowed.     Before  taking  an  anesthetic,  a  thorough 

1  Crile  has  pointed  out  that  general  anesthesia  secured  in  the  usual  way  does 
not  prevent  nocuous  impulses  from  the  seat  of  opeiation  reaching  the  brain  along 
afferent  nerves.  If,  however,  the  usual  methods  adopted  to  secure  local  anesthesia 
are  added  to  the  general  anesthetic  these  nocuous  associations  are  avoided.  To 
this  principle  of  operative  surgery  he  has  given  the  name  Anoci-association. 


^AXESTinCSIA    AM)   AXK.STU KTICS  149 

physical  cxainiiiiitioii  of  tlir  lu'iirt  and  Iiiti^'s  should  hv  made,  and  the 
l)atieiit  should  reino\e  false  teeth,  ehe\viii<f  <^imi,  toi)aeeo,  etc.,  from  the 
mouth  as  well  as  hairi)iiis,  earrinj^s,  etc.  Home  surgeons  have  the  habit 
of  gi\iiig  a  hypodermic  injection  of  morphin  half  an  hour  before  com- 
mencing; the  anesthetic;  in  a  few  cases  it  is  valuable,  but  frequently, 
apart  from  beinji;  a  |)ure  waste  of  a  \ahial)le  dru<;,  it  is  actually  harm- 
ful. The  clothes  should  be  loosened  around  the  throat  and  so  dis- 
posed as  to  make  artificial  respiration  easy  in  case  of  emergency. 
I)uring  anesthetization  and  while  recovering  from  the  ef!'ects  of  anes- 
thetics, the  chests  and  shoulders  of  patients  should  be  carefully 
covered,  as  they  are  very  prone  to  catch  cold.  No  anesthetic  should 
be  administered  in  the  dark;  change  of  color  frequently  is  one  of  the 
most  easily  recognized  signs  of  danger,  and  unless  the  patient  is  being 
anesthetized  in  a  good  light  this  cannot  })e  appreciated.  The  fre- 
quency of  ether  deaths  in  negroes  is  probably  due  to  inability  to 
recognize  cyanosis  readily  in  them.  The  patient  should  be  supine, 
with  the  head  comfortably  supported,  especially  in  the  old  and  round- 
shouldered,  in  asthmatics,  etc.  Throughout  the  course  of  anestheti- 
zation the  anesthetizer  must  f)ay  strict  attention  to  his  own  duties, 
and  neither  attempt  to  follow  the  minute  details  of  the  operation  nor 
to  converse  on  irrelevant  topics  with  bystanders.  He  is  responsible 
for  the  life  of  the  patient  quite  as  much  as  the  surgeon;  and  it  is  a 
sad  fact  that  the  disproportionate  number  of  deaths  from  anesthesia 
which  occur  during  trivial  operations  is  usually  due  to  carelessness 
of  the  anesthetist.  With  an  ear  for  respirations,  a  finger  on  the  tem- 
poral pulse,  and  an  eye  on  the  patient's  pupils,  the  anesthetist  need 
not  fear  to  have  his  attention  wander  or  to  meet  with  unforeseen 
accidents. 

Ether  is  the  safest  general  anesthetic  for  major  surgery,  and  probably 
is  the  most  widely  employed.  Hewitt  places  its  death  rate  at  1  in 
16,000,  five  times  safer  than  chloroform,  though  slightly  less  safe  than 
nitrous  oxide.  Ether  (ethyl  oxidej  is  a  heavy,  highly  inflammable 
liquid  of  strong  pungent  odor.  Its  vapor  is  heavier  than  air,  and 
sinks  to  the  floor;  hence  all  lights  should  be  kept  high  above  the 
operating  table,  as  occasionally  patients  have  been  seriously  burned 
by  ignition  of  ether  fumes.  I  prefer  to  administer  it  by  the  so-called 
"open,   drop-method,"   as  follows: 

The  patient's  cheeks,  nose,  and  lips  may  be  greased  with  vaselin 
to  prevent  the  rubefacient  effect  of  the  ether.  Place  eight  to  twelve 
layers  of  dry  wide-meshed  gauze  across  the  patient's  mouth  and  nose, 
and  ask  him  if  he  can  breathe  through  the  gauze.  He  always  answers 
"yes."  Then  directing  him  to  shut  his  eyes  and  mouth,  and  to  breathe 
through  his  nose,  hold  the  gauze  lightly  in  place,  but  do  not  exclude 
all  the  air  from  under  its  edges;  drop  the  ether  gently  over  the  gauze, 
one  drop  every  second  or  so,  moistening  an  area  an  inch  and  a  half  in 
diameter  just  below  the  tip  of  the  nose  (Fig.  99).  When  given  thus 
slowly  very  little  if  any  respiratory  irritation  is  produced,  the  patient 
continues  to  breathe  in  his  natural  wav,  and  bv  the  time  two  ounces 


150 


SURGICAL   TECHNIQUE 


have  been  administered  he  is  usually  unconscious,  not  having  exhibited 
any  "stage  of  excitement."  The  lower  jaw  should  be  constantly  held 
forward  by  the  fingers  placed  back  of  the  angle,  on  the  ramus,  as 
anesthesia  paralyzes  the  muscles,  and  unless  supported  the  jaw  may 
fall  backward  and  allow  the  base  of  the  tongue  to  force  the  epiglottis 
over  the  larynx.  When  the  respirations  become  mechanical,  like 
those  of  sleep,  the  pupils  are  found  contracted  but  still  reacting  to 
light  and  the  conjunctival  reflexes  are  abolished;  then,  after  a  little 
more  ether  is  administered  muscular  relaxation  becomes  complete.  The 
time  consumed  is  usually  from  ten  to  fifteen  minutes.  The  operation 
may  then  be  commenced.^  The  time  may  be  shortened  by  excluding 
air  more  completely :  this  is  easily  accomplished  by  keeping  the  margins 
of  the  gauze  in  contact  with  the  patient's  face,  and  by  adding  more 
dry  gauze  on  top  and  using  it  as  a  roof  under  which  to  drop  the  ether. 
This  concentrates  the  ether  vapor,  and  requires  less  ether;  but  unless 
cautiously  and  gradually  done  is  apt  to  cause  choking.  The  anesthe- 
tist should  never  give  enough  ether  to  cause  the  pupils  to  dilate;  if  they 


Fig.  99. 


Hospital. 


are  kept  contracted,  but  reacting  to  light,  the  patient  is  in  the  proper 
state  for  operation.  Frequently  during  the  course  of  an  operation  it 
may  be  possible  to  let  the  patient  come  so  far  from  under  the  influence 
of  ether  as  to  allow  his  pupils  to  return  to  their  normal  dilated  state, 
which  should  not  be  mistaken  for  the  dilated  state,  without  reaction 
to  light,  present  in  ad^■anced  ether  poisoning.  Some  operators  prefer 
and  others  will  not  allow  the  anesthetist  to  let  the  patient  "come 
to"  from  time  to  time.  Such  idiosyncrasies  must  be  learned  by 
experience. 

In  giving  ether  to  children,  who  are  not  reasonable  enough  to  lie 
still  and  breathe  quietly,  it  is  better  to  pour  a  dram  of  ether  at  once  on 
the  g&uze,  and  hold  this  firmly  in  contact  with  the  face.    After  a  short 

1  Many  very  short  operations  (half  a  minute)  may  be  done  during  the  stage 
known  as  "primary  anesthesia,''  described  many  years  ago  by  Packard.  The 
patient  is  directed  to  hold  one  arm  aloft,  when  inhalation.^  are  begun,  and  to  hold 
it  up  as  long  as  possible.  The  moment  the  arm  drops  is  the  opportime  time  for 
surgical  intervention.  In  Germany  this  state  of  first  insensibility  from  the 
anesthetic  is  known  as  the  "Ether  Rausch." 


ANESTHESIA   AND  ANESTHETICS  151 

striiji^lt',  iiiid  liokiiiij;  tlic  hrcatli  until  tli(jr()iif:;liiy  "out  of  breath," 
tiu'  child  will  take  a  few  deep  ins])iratioiis,  and  hy  so  floing  will  pass 
(•((inpletcly  under  the  influence  of  the  ether  in  a  \ery  much  shorter 
time  and  with  \ery  much  less  discomfort  and  danger  to  himself  than 
if  tiie  strug^de  had  been  prolonged  hy  attempting  to  administer  the 
ether  hy  the  droj)-method. 

Certain  accidcnh-  may  occur  during  etherization:  (1)  When  ether  is 
first  administered,  the  patient  may  stop  breathing.  This  usually  is 
due  to  neglect  of  the  precaution  to  start  the  patient  breathing  through 
the  gauze  before  any  ether  is  dropped  on  it,  or  to  pouring  on  a  quantity 
of  ether  instead  of  giving  it  drop  by  drop.  It  is  treated  by  removing 
the  gauze,  allowing  the  patient  to  breathe  air,  and  then  beginning 
o\er  again.  (2)  The  patient,  if  an  alcoholic,  or  if  he  has  taken  ether 
frequently  before,  may  be  unduly  exhilarated  by  the  stimulating  effect 
of  the  ether.  Hence  it  may  be  necessary  to  use  forcible  restraint, 
and  preparation  should  accordingly  be  made.  So  long  as  respiration 
is  good,  the  administration  of  more  ether  is  indicated,  as  there  are 
very  few  patients,  indeed,  who  do  not  succumb  to  its  influence  in  a 
short  time.  (3)  The  patient's  throat  may  fill  up  with  mucus,  making 
respiration  difficult,  and  producing  cyanosis.  This  generally  is  due 
to  too  rapid  administration  of  ether,  to  neglect  to  hold  the  jaw  forward, 
or  to  a  preexisting  bronchitis,  etc.  It  is  best  treated  by  pulling  the 
jaw  forward,  as  already  described,  thus  opening  the  larynx;  by  turning 
the  head  to  one  side,  or  letting  it  hang  over  the  edge  of  the  table,  thus 
allowing  the  secretions  to  accumulate  in  the  cheek  or  to  run  out  of 
the  mouth;  and  finally  by  the  use  of  a  mouth-gag  with  direct  removal 
of  the  mucus  by  sponging.  The  mouth-gag  is  rarely  required  by  a  good 
etherizer;  but  it  should  always  be  at  hand  for  emergencies.  Marine 
sponges  are  best  for  this  purpose;  each  should  be  about  an  inch  and 
a  half  in  diameter,  freshly 
wrung  dry  out  of  luke-warm 
water,  and  fixed  firmly  in  a 
long  handle.  When  the  jaws 
have  })een  opened  by  the 
gag,  the  tongue  is  grasped 

with  gauze  or  a  suitable  for-  Fig.  lOO.— Tongue  forceps. 

ceps  (Fig.  100),  and  pulled 

forward  and  upward.  This  alone  may  make  respiration  easier.  If 
necessary,  the  sponges  are  to  be  passed  back  into  the  pharynx,  and 
by  a  combined  sweeping  and  rotary  motion  are  made  to  collect  as 
much  mucus  as  possible.  (4)  The  patient  may  stop  breathing  from 
no  foreseen  cause.  This  frequently  is  due  to  the  administration  of 
too  much  ether,  occasionally  to  reflex  inliibitiou  from  injudicious 
traction  on  the  tongue  or  sponging,  and  rarely  to  the  direct  shock  of 
the  operation.  It  is  treated  by  artificial  respiration,  by  hypodermic 
stimulation,  and  by  inhalations  of  ammonia  and  oxygen  when  once 
respiration  is  restored.  (5)  Vomiting  occurs  from  neglect  to  abstain 
from  food  before  operation,  but  will  not  occur  after  anesthesia  is  once 


152  SURGICAL   TECHNIQUE 

complete,  unless  the  patient  is  allowed  to  come  out  of  the  anesthetic 
too  far. 

Chloroform. — One  death  among  every  3749  chloroform  anesthesias 
is  attributed  to  the  action  of  the  drug.  Its  action  is  more  rapid  than 
that  of  ether,  and  the  zone  of  safety  is  much  narrower.  It  has  been 
said  that  the  danger  signals  appear  and  the  collision  occurs  at  the 
same  instant;  there  is  not  sufficient  warning,  as  there  is  in  etheriza- 
tion, for  disaster  to  be  avoided.  The  most  important  thing  in  chloro- 
form anesthesia  is  to  allow  the  mixture  of  plenty  of  air  with  the  inhaled 

vapor.  On  this  account  I 
think  the  simplest  way  to 
administer  chloroform  is  by 
dropping  it  slowly  on  one 
or  two  thicknesses  of  gauze 
stretched  over  a  wire  frame, 
made  to  fit  over  the  mouth 
and  nose  in  such  a  way  that 
the  part  of  the  gauze  moist- 
FiG.  101.— Chloroform  inhaler.  encd  by  the  cliloroform  is 

always  half  an  inch  or  more 
di.-^tant  from  the  patient's  lips  (Fig.  101).  Even  stricter  attention  to 
the  pulse  and  respiration  is  required  than  in  giving  ether;  but  a  stage 
of  excitement  scarcely  ever  occurs,  little  or  no  bronchial  irritation  is 
produced,  and  vomiting  during  recovery  from  anesthesia  is  very 
unusual. 

Ethyl  chloride  is  a  seductive  but  dangerous  anesthetic.  It  acts  as 
quickly  as,  and  even  more  pleasantly  than  chloroform. 

Xitroiis  oxide,  a  gas  which  is  universally  employed  for  minor 
dental  operations,  may  be  equally  well  employed  in  surgery  for  short 
operations  where  complete  muscular  relaxation  is  not  required.  It 
exerts  its  influence  in  less  than  a  minute  and  is  the  least  unpleasant 
anesthetic  to  take.  It  acts  largely  by  causing  an  accumulation  in  the 
blood  of  carbon  dioxide.  Special  apparatus  is  used,  including  a  tank 
containing  the  gas,  a  face  mask  with  suitable  valves  to  admit  or  exclude 
air  or  oxygen  in  conjunction  with  the  nitrous  oxide,  and  a  rubber 
bag,  inserted  between  the  tank  and  the  mask,  in  which  the  gas  collects, 
but  from  which  the  expired  air  is  excluded  by  an  automatic  valve. 
When  a  suitable  admixture  of  oxygen  is  permitted,  skilful  anesthetists 
may  prolong  the  duration  of  anesthesia  for  an  hour  or  more.  Nitrous 
oxide  frequently  is  used  to  induce  anesthesia,  ether  or  chloroform  being 
substituted  later.  As  I  have  seen  it  used  in  this  way  I  have  not  been 
able  to  see  any  advantages  over  the  skilful  administration  of  ether 
from  the  start;  but  when  nitrous  oxide  and  oxygen  are  used  alone, 
without  any  recourse  to  ether,  recovery  from  the  anesthetic  occurs 
much  more  promptly,  and  there  are  no  unpleasant  after-effects. 

Clioice  of  a  General  Anesthetic. — Unless  contraindicated,  ether  is 
to  be  preferred,  because  it  is  the  safest.  Its  greatest  danger  is  post- 
operative bronchitis  or  pneumonia ;  but  with  proper  precautions  against 


ANESTHESIA   A.\D  ANESTHETICS  153 

exposure  of  the  patieijt,  and  1)\'  ,u;i\iii<i;  it  drop  !)>•  drop,  such  com- 
])Hcations  are  not  to  l)e  feared.  Moreoxcr,  it  is  Ixtter  for  a  patient 
to  he  nauseated  and  to  ha\'e  hronchial  irritation  after  reeo\ery  from 
etlier  than  for  liini  to  he  killed  hy  chloroform  or  ethyl  chloride.  In 
cases  where  bronchitis,  phthisis,  etc.,  exist,  or  where  the  kidneys  are 
seriously  diseased,  and  where  some  general  anesthetic  has  to  be 
employed,  nitrous  oxide  and  oxygen  should  be  ])referred.  Chloroform 
is  particularly  to  be  avoided  in  cases  of  heart  lesion  not  properly 
compensated,  and  in  cases  of  shock.  Nitrous  oxide  causes  cyanosis, 
stertor,  and  muscular  regidity,  with  such  increase  of  blood  pressure 
that  it  is  esj)ecially  contraindicated  in  patients  with  arteriosclerosis; 
its  successful  administration  requires  much  more  skill  and  experience 
than  does  that  of  ether,  but  when  skilful  assistance  is  available,  and 
the  operation  will  not  consume  more  than  thirty  or  forty  minutes,  it 
is  when  combined  with  oxygen  a  safer  and  more  desirable  anesthetic 
than  is  ether  for  patients  with  visceral  lesions  other  than  those  of  the 
vascular  system. 

Administration  of  General  Anesthetic  for  Special  Operations. — Head 
AND  Neck. — It  is  found  often  in  operations  on  the  head  and  neck 
that  the  anesthetist  is  very  much  in  the  way,  and  that  the  progress 
of  the  operation  interferes  with  the  proper  administration  of 
the  anesthetic.  One  of  the  simplest  methods  of  o\ercoming  this  is 
to  have  the  ether  vapor  conducted  to  the  patient's  mouth  through 
a  tube,  so  that  the  anesthetist  may  stand  at  some  distance.  This  is 
accomplished  by  standing  the  ether  bottle  in  a  pan  of  warm  water, 
to  increase  the  rapidity  of  vaporization.  Through  the  cork  of  the 
ether  bottle  pass  two  tubes — an  afferent  tube  which  is  connected 
with  a  hand  bulb,  and  an  efferent  tube  Avhich  is  three  or  four  feet  long 
and  leads  to  the  patient's  mouth.  If  a  hooked  metal  tube  is  attached 
at  the  mouth  end,  it  will  hang  in  the  angle  of  the  mouth  and  keep  its 
place  without  difficulty.  The  ether  vapor  has  never  caused,  in  my 
experience,  any  evidence  of  stomatitis.  If  its  irritating  effects  are 
feared,  the  vapor  may  be  conducted  by  tube  over  or  through  a 
bottle  of  water  before  entering  the  mouth.  The  patient  is  first 
anesthetized  in  the  usual  way,  and  when  thoroughly  relaxed,  the 
gauze  is  removed  from  the  face,  the  mouth  tube  introduced,  and  the 
ether  vapor  forced  into  the  mouth  by  use  of  the  hand  bulb. 

Crile's  plan  is  another  convenient  method.  After  the  patient  is 
anesthetized,  the  surgeon  passes  a  well  greased  tube  through  each 
nostril  to  the  naso-pharynx,  and  packs  the  mouth  loosely  with  gauze. 
The  outer  ends  of  the  nasal  tube  are  connected  by  a  Y-shaped  glass 
tube  to  a  long  rubber  tube,  at  the  far  end  of  which  is  a  funnel  lightly 
filled  with  gauze.  The  ether  is  then  administered  by  being  dropped 
on  the  gauze  in  the  funnel.  It  is  well  to  ha^'e  a  U-tube  inserted 
somewhere  in  the  tube  which  conducts  the  ether  vapor  to  the  patient, 
so  that  in  it  may  collect  any  condensation  from  the  ether  vapor. 

IxTRATHORACic  Operatioxs. — When  the  pleura  is  opened,  the  lung 
partially  collapses,  and  in  consequence  there   may  be  considerable 


154  SURGICAL  TECHNIQUE 

respiratory  <listiir})aiice  and  interference  with  the  a(hninistrati()ii  of  an 
anesthetic.  To  overcome  this  Sauer])rnch,  of  Breshm,  devised  (11)04) 
a  plan  for  operating  nnder  negative  atinuspheric  'prcwure,  thns  allowing 
the  Inng  to  remain  expanded.  In  this  method  the  patient  is  i)laced 
in  a  chamber  in  which  negative  pressure  can  be  induced;  his  head 
projects  through  an  opening  in  this  chamber,  and  a  rubber  collar 
fitting  closely  around  his  neck  makes  the  aperture  air-tight.  The  anes- 
thetist sits  outside  the  chamber,  while  the  surgeon  and  his  assistants 
must  remain  inside.  This  plan  of  operating  under  negative  pressure 
entails  expensive  apparatus,  and  a  specially  constructed  operating- 
room,  which  cannot  be  moved  from  place  to  place.  Dr.  Willy  Meyer, 
of  New  York,  is  the  chief  supporter  of  the  method  in  America,  and 
has  had  a  very  complete  operating  suite  constructed  in  the  German 
Hospital  in  that  city. 

Positive  Pressure  Method. — This  was  introduced  by  Brauer,  of 
Heidelberg,  very  soon  after  Sauerbruch's  method.  Here  the  patient's 
head  and  the  anesthetist  are  in  a  specially  constructed  chamber, 
in  which  the  atmospheric  pressure  may  be  increased,  by  suitable 
apparatus,  so  that  when  the  pleural  cavity  is  opened  the  lung  stays 
expanded.  This  appears  to  be  a  simpler  method  than  that  of  negative 
pressure,  and  seems  quite  as  efficient;  but  has  not  been  used  much 
in  this  country. 

Intratracheal  Insufflation. — Meltzer  and  Auer,  of  the  Rockefeller 
Institute,  New  York,  found  in  experiments  on  dogs,  in  1909,  that  if 
a  tube  was  passed  down  to  the  trachea  almost  to  its  bifurcation,  and 
if  air  mixed  with  ether  was  constantly  blown  in  through  this  tube  by 
suitable  bellows,  the  dog's  lungs  remained  expanded  even  when  both 
pleurae  were  widely  opened,  that  anesthesia  could  be  maintained  for 
hours,  and  that  it  was  impossible  to  kill  the  dogs  by  an  overdose  of  the 
anesthetic.  This  method  was  adapted  for  human  beings  by  Elsberg, 
of  New  York,  and  is  now  the  most  approved  plan  for  administering 
an  anesthetic  for  operations  on  the  lung,  the  thoracic  esophagus,  the 
cardiac  orifice  of  the  stomach  and  the  diaphragm.  It  is  a  great  con- 
venience also  in  operations  on  the  mouth  and  pharynx,  as  it  prevents 
aspiration  of  mucus  or  blood.  Briefly  described,  the  apparatus  is  as 
follows :  An  electric  motor  is  used  to  pump  the  air  through  a  bottle 
of  warm  water,  by  which  it  is  filtered,  warmed,  and  moistened.  The 
air  is  then  conducted  by  tube  to  the  ether  bottle,  where  the  tubing  is 
so  arranged  with  stopcocks  that  (1)  all  the  air  may  pass  directly  on 
to  the  patient  without  coming  into  contact  with  the  ether;  (2)  all  the 
air  may  pass  through  the  ether  bottle,  over  the  surface  of  the  ether, 
and  thus  become  saturated  with  the  anesthetic  before  reaching  the 
patient;  or  (3)  some  of  the  air  may  pass  directly  on  to  the  patient 
while  some  passes  through  the  ether  bottle  before  reaching  the 
patient.  Thus  the  amount  of  ether  to  be  administered  may  be  accu- 
rately regulated.  An  oxygen  tank  maybe  connected  with  the  tube 
leading  to  the  patient,  so  that  pure  oxygen  or  oxygen  mixed  with  air 
in  any  proportion  may  be  inhaled. 


ANESTHESIA   AND  ANESTHETICS  1.').') 

Tlie  tiilx'  leadinj;  from  the  ether  bottle  to  the  patient  is  eonneeted 
with  a  iiiaiiometer,  and  lias  a  ^  -cndinji,  one  branch  tor  connection  with 
the  intratracheal  tube,  and  the  other  to  be  used  as  a  cut  out,  to  allcjw 
collapse  of  the  lungs  at  any  instant  desired.  The  ai)paratus  may  be 
obtained  now  in  very  compact  form. 

The  intratracheal  tube  should  be  fairly  rigid,  of  the  length  of  a 
stomach  tube,  and  about  half  the  diameter  of  the  trachea.  The 
patient  is  anesthetized  in  the  usual  manner,  and  the  larynx  and 
pharynx  are  thoroughly  anesthetized  with  coeain  solution  (10  per 
cent.).  The  tube,  previously  sterilized,  is  then  passed  through  the 
lar>nx  into  the  trachea.  This  is  facilitated  by  the  use  of  a  broncho- 
sc-opic  tube  or  speculum.  When  the  intratracheal  tube  is  momentarily 
arrestefl  at  the  bifurcation  of  the  trachea,  it  is  withdrawn  a})out  an 
inch.  If  the  tube  is  in  correct  position  air  will  enter  both  lungs;  if 
it  has  been  pushed  in  so  far  as  to  be  arrested  at  the  division  of  the  right 
bronchus  no  air  will  enter  or  leave  the  left  lung.  ^Yhen  in  ])roj)er  posi- 
tion, the  tube  is  clamped  just  outside  the  dental  margin  by  a  frame 
supported  on  the  ears,  resembling  a  spectacle  frame.  "The  tul)e  is 
now  connected  with  the  air  pressure  apparatus,  and  air  is  blown 
through  at  a  pressure  of  10  mm.  of  mercury.  After  several  minutes, 
the  pressure  is  raised  to  20  mm.  and  the  operation  can  be  begun. 
When  the  pressure  of  the  inflowing  air  and  ether  equals  20  mm.  of 
mercury,  inspiration  and  expiration  will  continue,  air  being  inhaled 
and  exhalkl  by  the  side  of  the  tube.  If  there  existed  a  profuse  secre- 
tion of  mucus  in  the  pharynx  and  trachea,  this  will  be  found  to  have 
ceased  soon  after  the  insufflation  was  begun.  Every  two  to  three 
minutes,  an  assistant  opens  a  vent  so  that  the  current  of  air  which 
enters  the  tube  is  interrupted  for  a  moment."     (Elsberg.) 

Xo  ill  eft'ects  have  been  noted  from  anesthesia  maintained  by  this 
method.  F'ar  from  favoring  pulmonary  complications,  it  seems  to 
prevent  them. 

Local  Anesthesia  may  be  secured  by  freezing  the  skin  with  a  mix- 
ture of  ice  and  salt,  or  by  a  spray  of  ethyl  chloride  or  rhigolene.  The 
skin  becomes  white,  covered  with  minute  crystals  of  ice,  and  is  rendered 
very  tough.  The  anesthesia  lasts  only  a  few  seconds,  but  sufficiently 
long  for  opening  superficial  abscesses,  etc.  If  the  patient  only  knew 
that  freezing  hurts  as  much  or  more  than  a  sudden  stab  with  a  sharp 
bistoury,  he  probably  would  prefer  to  have  this  form  of  local  anes- 
thesia abandoned. 

Coeain  and  eiicain  are  the  chief  agents  used  for  local  anesthesia. 
Solutions  of  coeain  are  unstable  chemically,  and  are  destroyed  by 
repeated  boiling;  in  emergency,  boiling  for  a  few  minutes  does  not 
impair  their  value.  Eucain  {eucain  B)  is  not  so  toxic  as  coeain,  is 
not  destroyed  by  boiling,  and  is  quite  as  efficient;  but  the  duration 
of  anesthesia  is  shorter  than  that  produced  by  coeain.  In  general, 
eucain  is  to  be  preferred.  The  addition  of  saline  solution,  to  make 
the  solution  isotonic  with  the  blood,  and  of  adrenalin  to  constringe 
the  capillaries,  thus  preventing  diffusion  of  the  anesthetic  and  local 


156  SURGICAL    TEmXIQUE 

edema,  renders  the  use  of  local  anesthesia  much  more  satisfac- 
tory. The  apphcation  of  an  Esmarch  band  above  the  seat  of 
operation  also  prevents  diffusion  of  the  anesthetic.  Cocain  tablets 
which  can  be  sterilized  by  dry  heat,  are  now  on  the  market.  Mitchell 
(190Sj  recommends  that  each  tablet  be  sterilized  in  a  glass  flask  as 
needed,  being  added  to  the  sterile  saline  solution  just  beff>re  it  is  to 
be  used.  Finally,  the  adrenalin  solution  is  to  be  added  drop  by  drop 
to  the  required  amount.    He  gives  the  following  formulae  from  Braun: 

A. 
Cocain  hydrochlorate,  0.1  grm.  (1.5  grain) 

Physiologica]  salt  solution,  100  c.c. 

(jTT  per  cent.t 
Adrenalin  (1  to  1000)  5  drops. 

B. 
Cocain  hydrochlorate,  0.05  grm.  (0.75  grain) 

Physiological  salt  solution  5  -cc. 

(tV  per  cent.) 
Adrenalin  (1  to  1000)  10  drops. 

Formula  A  represents  a  1  to  1000  cocain  solution,  anrl  may  be  further 
diluted  with  saline  solution  if  large  amounts  are  to  be  used,  as  in  long 
operations  by  Schleich's  infiltration  anesthesia;  while  Formula  B  (a 
1  per  cent,  solution  of  cocain)  is  used  for  operations  requiring  only  one 
or  two  h^•podermic  injections,  when  the  whole  amount  of  the  formula 
may  be  employed  safely.  For  applications  to  mucous  membranes 
(eye,  throat,  urethra,  bladder;,  a  2  per  cent,  solution  may  be  used, 
and  sometimes  a  4  per  cent,  solution.  It  is  dropped  on  the  surface  of 
the  eye,  and  is  applied  to  the  nose  and  throat  by  a  pledget  of  absorbent 
cotton:  while  it  is  injected  into  the  urethra  and  bladder  by  means 
of  the  urethral  syringe,  catheter,  or  in.>tillator. 

Hypodermic  Use. — The  skin  is  pinched  up  as  in  giving  a  hypodermic 
injection,  but  the  needle,  which  enters  at  one  end  of  the  proposed 
incision,  with  its  point  directed  toward  the  other  end,  is  not  passed 
into  the  subcutaneous  tissues,  but  its  point  is  arrested  in  the  true  skin, 
the  first  injection  being  endodermic,  not  hypodermic.  As  the  piston 
of  the  syringe  is  pushed  down,  a  distinct  wheal  is  raised  in  the 
skin;  the  needle  is  then  pushed  on  within  the  true  skin  until  its 
point  reaches  the  limit  of  the  wheal,  when  another  wheal  is  pro- 
duced, and  so  on  until  the  entire  length  of  the  needle  has  entered. 
It  is  then  withdrawn  and  reintroduced  at  the  furthest  point  reached, 
and  the  process  is  repeated  until  the  line  of  the  entire  incision  has 
been  anesthetized.  An  incision  may  then  be  made  through  the  skin, 
and,  with  a  few  added  drops  here  and  there  as  required,  this  degree  of 
anesthesia  will  suffice  for  circumcision,  removal  of  sebaceous  cysts  and 
small  tumors,  opening  cold  abscesses,  etc.  For  such  cases  Formula  B 
may  be  used.  When  a  more  extensive  operation  is  imdertaken,  as 
one  for  hernia,  goitre,  etc.,  it  is  best  to  use  the  weaker  solution  (dilu- 
tions of  Formula  A),  and  special  attention  must  be  paid  to  nerves, 
bloodvessels,  and  connective  tissue  bundles  (infiltration  anesthesia). 
Almost  any  quantity  of  the  weaker  solutions  may  be  used,  especially 


ANESTHESIA  AM)  ANESTHETICS 


157 


when  local  aiu'stlicsiji  is  aided  by  constriction  of  the  linih  al)o\'e  the 
seat  of  operation. 

Nerve  hloek'uuj  may  he  acconij)lishe(l  l)y  perineural  or  endoneural 
injections,  the  latter  being  preferable  as  more  accurate  and  permitting 
a  wider  range  of  o])erative  procedure.  Certain  nerves  (ulnar,  jjer- 
oneal)  may  be  reached  directly,  but  usually  it  is  necessary  to  bare 
the  ner\e  by  the  hypodermic  use  of  cocain  as  already  described.  In 
the  endoneural  method  ((Vile,  Pushing,  IMatas),  the  cocain  is  injected 
directly  among  the  nerve  fibres  of  the  main  trunks  conveying  sensa- 
tion from  the  region  to  })e  operated  on.  Comjjlete  anesthesia  follows, 
and  as  no  sensory  impulses  can  reach  the  nerve  centres  surgical  shock 
is  nuich  diminished  or  totally  prevented,  a  fact  which  is  of  value  in 
many  amputations.  I  generally  employ  2  per  cent,  solutions  for  this 
purpose. 


Fig.   102. — vSpinal  analgesia.     Needle    between    spines  of  second  and  third  lumbar 
vertebrae.      Posterior  superior  iliac   spines   marked   with   iodin.      Episcopal   Hospital. 

Spinal  anesthesia  is  closely  allied  to  nerve  blocking.  It  was  sug- 
gested in  1885  by  Leonard  Corning,  of  New  York;  was  employed  in 
1889  by  Tuffier;  and  has  been  more  widely  used  abroad  than  in  this 
country.  The  anesthetic  acts  on  the  roots  of  the  spinal  nerves,  not  on 
the  cord  itself.  The  injection  is  made  usually  in  the  second  or  third 
lumbar  interspace  (Fig.  102);  as  a  rule,  anesthesia  (which  aflFects  both 
motor  and  sensory  impulses,  especially  the  latter)  extends  only  to  the 
region  of  the  waist,  and  therefore  operations  best  suited  for  spinal 
anesthesia  are  those  on  the  lower  extremities  or  pelvis.  Stovain  (4 
per  cent,  solution)  usually  is  preferred  to  other  anesthetics,  and  is 
that  which  I  am  myself  accustomed  to  use.  About  1.5  to  2  c.c.  are 
employed.  The  anesthesia  begins  in  a  few  minutes  and  lasts  nearly 
an  hour.  As  positive  contraindications  to  spinal  anesthesia  may  be 
mentioned:  advanced  cachexia,  bilateral  nephritis  with  scanty  excre- 
tion, myocarditis,  pericarditis  with  effusion,  non-compensated  cardiac 
disease.  ]\Iany  operations  in  which  spinal  anesthesia  may  seem 
desirable  can  be  done  equally  well  under  local  anesthesia ;  but  for  rectal 
operations  and  prostatectomy  spinal  anesthesia  is  to  be  preferred,  if 
a  general  anesthetic  cannot  be  employed. 


158  SURGICAL   TECHNIQUE 

Vein  anesthesia  is  a  term  used  to  describe  a  method  employed  by 
Bier  (1908).  He  has  used  it  in  134  operations.  It  is  appHcable  to  any 
operation  on  the  extremities.  He  first  renders  the  part  bloodless  by 
Esmarch's  method  (p.  433),  and  cuts  off  the  general  circulation  by 
broad  elastic  bands  above  and  below  the  seat  of  operation;  exposing 
then  a  superficial  vein,  he  injects  into  the  vein  40  to  80  c.c.  of  a  0.5 
per  cent,  solution  of  novocain  in  saline  solution;  the  solution  diffuses 
through  the  capillaries  of  the  area  sequestrated  from  the  general 
circulation,  rendering  every  subsequent  manipulation  painless.  At 
the  conclusion  of  the  operation  the  anesthetic  solution  may  be  removed 
by  washing  out  the  veins  with  saline  solution,  but  this  is  not  always 
necessary,  as  most  of  the  novocain  escapes  into  the  wound  through 
the  capillaries  dividt  d  during  the  operation. 


CHAPTER  VI. 
INJURIES  AND  THEIR  EFEECTS. 


LOCAL  EFFECTS  OF  INJURIES. 

The  local  effects  of  injury  depeiid  on  the  part  injured,  as  well  as 
on  the  force  exerted  by,  and  the  manner  of  action  of  the  vulneratin<i; 
body.  A  smart  blow  with  a  rope  will  produce  a  wheal;  if  the  roi)e 
slips  rapidly  through  the  hands  with  violent  friction,  a  l)rush-})urn 
will  result;  but  if  the  rope  is  twisted  tightly  around  the  part,  strangula- 
tion will  occur.  Striking  the  foot  against  a  large  stone  will  cause  a 
contusion,  but  if  the  same  stone  falls  on  the  leg  it  may  fracture  the 
bones.  Injury  of  parts  with  abundant  and  lax  subcutaneous  tissues 
will  be  attended  by  much  greater  swelling  than  where  these  tissues 
are  firm  and  resistant;  injuries  of  certain 
parts  are  much  more  dangerous  than 
similar  or  severer  injury  expended  upon 
other  parts  not  so  highly  specialized  or  so 
vascular. 

The  local  efi'ects  of  heat,  cold,  etc.,  are 
considered  in  Chapter  IX. 

Abrasions. — An  abrasion  is  an  injury  in 
which  merely  the  epiderm  has  been  re- 
moved by  slight  friction;  brush-burns, 
produced  by  violent  friction,  resemble 
contused  wounds  (p.  167).  An  excoriation 
is  an  injury  produced  by  scratching  or 
scraping  which  involves  the  corium.  The 
resulting  ulcers  heal  readily  when  properly 
protected. 

Contusions. — A  contusion  is  a  subcuta- 
neous injury  of  the  soft  parts  produced  by 
blunt  force  (kicks,  falls,  etc.).  There  is  al- 
ways a  certain  amount  of  blood  extravasated 
among  the  lacerated  tissues;  when  this 
blood  is  visible  in  moderate  amount  be- 
neath the  skin,  it  is  termed  an  ecchymosis; 
and  as  it  undergoes  absorption  it  passes 

through  various  shades  of  purple,  green,  black,  and  blue.  A  very 
minute  ecchymosis  is  called  a  petechia.  Bloofl  extravasated  beneath 
the  conjunctiva  remains  bright  red  a  long  time,  owing  to  oxidation 
through  the  thin  overlying  tissues.  When  enough  blood  is  extrav- 
asated  to  cause  an   appreciable   collection  of  fluid,   it   is  called   a 


Fig.  103.— Hciiial«.i,,:i  .ii  left 
thigh  ten  clays  after  a  full ;  aldo 
fracture  of  shaft  of  left  hu- 
merus. Age  forty-eight  years. 
Episcopal  Hospital. 


160  INJURIES  AND   THEIR  EFFECTS 

hematoma;  or  if  clotted  a  thrombus.  The  skin  itself,  though  more 
resistant  than  the  subcutaneous  tissues,  does  not  always  escape 
injury  in  a  contusion;  such  injun-  is  manifested  in  the  course  of 
twelve  to  twenty-four  hours  by  vesicles,  blisters,  and  bullae.  These 
usually  appear  before  the  ecchymoses,  which  rarely  become  apparent 
until  the  second  or  third  day.  The  diacpiosis  of  a  contusion  is  easy, 
being  based  on  the  history  of  injury  by  blunt  force;  on  the  indentation 
of  the  soft  parts  (especially  on  the  scalp),  often  persisting  when  the 
patient  is  seen  soon  after  the  accident;  on  the  local  tenderness  which 
is  rapidly  followed  by  swelling,  extravasation,  and  ecchymosis.  The 
yrognosis  is  good,  unless  there  is  some  undetected  injury  to  nerves, 
bloodvessels,  bones,  joints,  or  internal  organs.  The  hematoma  which 
forms  seldom  causes  anxiety;  usually  the  bleeding  ceases  spon- 
taneously, or  under  the  application  of  cold,  elevation  of  the  part, 
moderate  pressure,  etc.  The  treatment  consists  in  securing  local  rest, 
in  applying  anodyne  or  slightly  stimulating  fomentations  (arnica, 
dilute  alcohol,  ichthyol  ointment),  and  in  promoting  absorption  of 
the  hematoma  at  a  later  date  by  gentle  massage,  firm  bandaging, 
etc.     Constitutional  treatment  is  rarely  required. 

Strangulation. — Strangulation  of  a  part  results  from  the  inter- 
ruption of  the  circulation  by  the  application  of  circular  constriction 
so  tight  and  sufficiently  long  as  to  cause  passive  changes  somewhat 
resembling  those  seen  in  contusion.  If  the  strangulation  is  not 
relieved  (by  elevation,  by  division  of  constricting  bands,  etc.),  the 
part  dies,  and  is  removed  as  a  slough  by  granulations  at  the  point  of 
constriction.  All  the  dangers  from  infection,  present  in  gangrene 
from  other  causes,  arise,  and  life  is  occasionally  lost. 

Wounds. — A  wound  is  a  solution  of  continuity  of  the  soft  tissues 
the  result  of  violence.  A  wound  is  open  if  the  skin  is  as  widely  divided 
as  the  underlying  structures;  or  suhcutaneous  if  the  division  of  the 
skin  is  insignificant.  Wounds  are  also  described  as  incised,  lacerated, 
contused,  punctured,  or  poisoned.  Gunshot  wounds,  which  resemble 
contused  wounds,  are  considered  in  Chapter  VII. 

Incised  Wounds. — Incised  wounds,  which  may  be  regarded  as  the 
normal  type,  are  those  made  by  clean  cuts  with  sharp  instruments, 
and  are  produced  by  the  surgeon  in  every  cutting  operation.  ]\Iost 
accidental  wounds  partake  more  of  the  nature  of  lacerated  than 
incised  wounds,  as  the  instruments  by  which  they  are  inflicted  (pocket 
knives,  broken  glass,  axes,  etc.),  are  not  as  sharp  as  surgical  instru- 
ments, and  even  if  sharp  (as  razors)  are  not  wielded  with  the  delicacy 
and  precision  necessary  in  surgery.  Pain,  hemorrhage,  and  gaping 
are  the  main  symptoms  of  incised  wounds.  The  pain  varies  with 
the  size  of  the  wound,  with  the  sensibility  of  the  part  wounded,  and 
with  the  manner  in  which  the  wound  is  produced.  A  large  wound 
hurts  more  than  a  small  one;  wounds  of  the  face  and  hands  hurt 
more  than  those  of  the  back  and  buttocks  where  the  cutaneous  nerves 
are  less  developed;  and  a  quickly  made  incision  causes  less  pain 
than  one  which  is  bungled.    The  hemorrhage  depends  largely  on  the 


IXCISED  WOUXDS  1()1 

location  of  the  wound,  and  on  the  inij)Hcation  of  hirj^e  vessels.  Wounds 
of  tlie  face  and  scalj)  bleed  profusely,  because  of  the  vascularity  of 
these  ])arts.  and  because  in  the  scalp  the  vessels  cannot  contract 
and  retract.  The  uai)int,'  of  a  wound  (lejx'nds  on  the  natural  elasticity 
of  the  tissues  dixided.  A  wound  which  runs  in  the  direction  of  the 
natural  folds  of  the  skin  will  ^'ape  less  than  one  which  crosses  these 
folds;  one  which  divides  muscles  transversely  will  gape  widely;  the 
divided  ends  of  tendons,  arteries,  and  nerves  may  retract  for  several 
inches  from  the  ])oint  of  division. 

Pnxr.s-s  of  IliaJing  in  Incised  Wounds. — As  the  result  of  tiie  irrita- 
tion produced  by  the  vulnerating  body,  tissue  changes  occur  which 
are  pathologically  identical  with  those  seen  in  the  process  of  inflam- 
mation; so  that  the  healing  of  an  incised  wound  is  the  same  as  Repair 
after  Inflammation  (p.  29).  It  is  convenient  to  recognize  different 
ways  in  which  union  occurs  after  a  wound  has  been  inflicted,  although 
the  ditterence  is  purely  quantitative,  depending  on  the  extent  of 
reaction  necessitated,  and  though  the  processes,  so  far  as  they  extend, 
are  identical  in  all  cases.  Historically,  three  ways  of  union  are  recog- 
nized: (1)  By  immediate  union  (to  which  the  term  "first  intention" 
as  used  by  Hunter  (1784)^  is  correctly  applied);  (2)  by  adhesion,  as 
understood  by  Paget  (1853);  and  (3)  by  granulation,  or  by  second 
intention. 

1.  Immediate  Union. — If  the  edges  of  an  aseptic  incised  wound 
are  accurately  apposed  so  that  each  tissue  meets  its  corresponding 
structure  in  the  other  lip  of  the  wound;  and  if  no  foreign  particles, 
even  if  aseptic,  or  no  blood-clots,  remain  between  the  lips  of  the 
wound,  then  the  reactive  process  may  extend  only  to  the  stage 
described  as  that  of  "temporary  hypertrophy."  No  inflammatory 
lymph  is  exuded,  no  granulation  tissue  forms,  and  the  wound  heals 
by  immediate  union,  or  by  the  first  intentiow^in  the  Hunterian  sense. 
Very  few  incisions  and  yet  fewer  wounds  heal  by  immediate  union; 
very  small  wounds  of  extremely  vascular  parts  (fingers,  face),  may 
occasionally  heal  without  the  process  of  reaction  having  extended 
beyond  the  stage  of  temporary  hypertrophy.  Such  wounds  when 
healed  leave  no  visible  scar — the  tissues  have  undergone  complete 
regeneration,  restitutio  ad  integrum. 

2.  Union  by  Adhesion. — When  the  insult  to  the  tissues  has  been 
greater,  or  when  the  tissues  themselves  have  been  less  able  to  repair 
the  damage,  the  process  of  reaction  extends  to  the  stage  of  lymph 
formation.  The  lips  of  the  wound  must  be  in  accurate  apposition, 
leaving  no  dead  spaces,  so  that  the  effused  inflammatory  lymph 
serves  as  a  framework  in  which  fibroblasts  and  granulation  tissue 
develop,  as  described  at  p.  30.  It  is  this  form  of  union  which  occurs 
in  the  vast  majority  of  aseptic  operative  incisions,  and  which  is  com- 
monly spoken  of  as  "union  by  the  first  intention,"  though  strictly 
speaking  this  term  should  be  reserved  for  immediate  union;  but  as 

'  It  is  the  "first  intention"  of  nature  to  heal  wounds  in  this  way. 
11 


162  INJURIES  AND   THEIR  EFFECTS 

for  at  least  seventy  years  it  has  been  erroneously  applied  by  the 
majority  of  surgeons,  it  is  perhaps  useless  to  register  a  protest  now. 
In  the  process  of  union  by  adhesion  a  scar  is  always  produced  extend- 
ing to  the  depths  of  the  incision,  but  is  least  conspicuous  in  wounds 
made  with  the  greatest  precision  and  attended  by  the  least  trauma; 
so  that  the  kind  of  scars  left  by  a  surgeon  in  operating  often  gi\-e  an 
idea  as  to  the  delicacy  and  neatness  of  his  operative  methods. 

3.  Ujiion  by  Granulation. — This  form  of  union,  also  known  as 
union  by  the  second  intention,  is  that  which  occurs  when  the  reaction- 
ary process  extends  to  the  stage  of  pyogenesis.  As  already  pointed 
out  (p.  27),  it  is  theoretically  possible  for  pus  to  be  formed  without 
the  intervention  of  microorganisms;  and  it  is  likewise  theoretically 
possible  for  wounds  to  unite  by  granulation  without  the  formation 
of  any  visible  pus:  but  for  either  of  these  events  to  occur  in  practice 
is  excessively  rare.  If  the  lips  of  the  wound  are  not  brought  into 
accurate  apposition,  the  gaping  surfaces  become  covered  with  visible 
granulations,  and  always,  I  believe,  some  pus  will  be  seen  on  the 
surface  of  the  healing  wound  (which  really  is' an  ulcer),  or  will  be 
absorbed  by  the  dressings.  The  process  of  cicatrization  and  con- 
traction is  pathologically  identical  with  that  seen  in  the  healing  of 
ulcers  (p.  53).  Union  by  secondary  adhesion  (the  third  intention)  is 
that  which  occurs  when  two  lips  of  a  granulating  wound  are  apposed 
by  sutures,  or  in  other  ways,  so  that  the  fibroblasts  and  granulations 
on  one  lip  grow  across  the  obliterated  gap  into  the  granulation  tissue 
on  the  opposite  lip,  thus  hastening  the  process  of  repair.  If  there 
is  much  discharge  from  the  wound  such  secondary  adhesion  will 
not  occur.  Healing  by  scabbing,  by  incrustation,  or  by  subcrustaceous 
cicatrization,  is  that  form  of  union  (l)y  adhesion  or  by  granulation) 
which  occm"s  under  a  scab  formed  of  effused  blood  and  lymph  mixed 
with  the  dust,  etc.,  which  collects  on  the  surface. 

Treatment  of  Incised  Wounds.- — The  first  effort  must  be  to  check 
hemorrhage  and  to  prevent  infection.  In  operating,  aseptic  or  anti- 
septic principles  will  be  strictly  adhered  to,  and  in  wounds  accidentally 
received  the  surgeon,  after  adopting  the  necessary  measures  for 
arresting  hemorrhage  (Chapter  X)  will  employ  such  methods  of 
cleansing  the  wound  and  the  surrounding  parts  as  have  already  been 
advised  in  Chapter  V  (p.  140).  Very  small  wounds  will  gape  so  little 
that  the  proper  use  of  plasters,  compresses,  bandages,  etc.,  will  keep 
the  edges  in  contact.  In  most  wounds,  however,  the  edges  must  be 
united  by  sutures. 

Sutures  are  made  of  absorbable  or  of  non-absorbable  material. 
Absorbable  sutures  are  usually  made  of  catgut,  which  may  be  pre- 
pared in  such  a  way  that  it  will  last  a  more  or  less  definite  time  in 
the  tissues  before  being  absorbed  (10-,  20-,  and  40-day  chromicized 
catgut).  Non-absorbable  sutures  are  made  of  linen,  silk,  silkworm 
gut,  silver  wire,  etc.  Interrupted  sutures  are  shown  in  Fig.  104,  each 
separate  stitch  being  independent  of  every  other  stitch.  Varieties 
of  the  interrupted  suture  are  the  twisted,  or  hare-lip  suture  (p.  636), 


METHODS  OF  SUTURE 


1G3 


and  tlic  quilli'd  suture  (Fij,'.  105).  Continuous  sutures  are  those  in 
which  several  or  all  of  the  individual  stitches  are  made  l)y  one  thread 
which  is  knotted  only  at  the  beginning  and  end  of  the  line  of  suture. 
\'ari()us  forms  of  contimious  suture  are  used  in  surgery;  the  overhand 
suture  (Fig.  UK))  is  most  frccjucntly  used,  and  is  well  adapted  for 
uniting  edges  of  fascia,  skin,  etc.,  on  which  there  is  not  much  tension; 


-ir\  a  i 


Fig.  104. — Iiitcrruptod  sutures;  each 
stitch  is  knotted  separately. 


Fig.  1U.5. — Quilled  sutures;  each  stitch 
is  double  and  tied  over  a  quill,  or  prefer- 
ably a  rubber  tube,  which  prevents  the 
stitches  from  cutting.  Useful  when  there 
is  much  tension  on  the  sutures. 


Fig.  106. — Continuous  (overhand)  suture. 


Fig.  107. — Chain  or  lock-stitch. 


Fig.  108. — Quilt  or  mattress  suture. 


Fig.  109. — Sutures  u.sed  to  repair  a  deep 
wound:  A,  superficial  suture  (through  the 
skin  only) ;  B.  deep  suture  (passing  deeply 
into  the  wound,  but  not  a  buried  suture) ; 
c,  c,  buried  sutures  (to  unite  peritoneum, 
deep  fascia,  etc.). 


Fig.  110. — Figure-of-eight  suture,  em- 
ployed to  unite  parietal  peritoneum,  deep 
fascia  and  skin. 


the  chain  or  lock-stitch  (Fig.  107)  is  useful  where  tension  is  greater; 
while  the  quilt  or  mattress  suture  (Fig.  108),  by  passing  deeply  into 
the  tissues,  is  useful  where  there  is  tension  on  the  deeper  parts,  as 
it  tends  to  evert  the  lips  of  the  wound.  Other  forms  of  continuous 
suture  are  used  in  intestinal  surgery  (Chapter  XXII).  A  suture  may 
be  superficial,  deep,  or  buried,  as  shown  in  Fig.  109.  As  a  rule  only 
absorbable  material  should  be  used  for  buried  sutures.    Deep  sutures, 


104 


INJURIES  AND  THEIR  EFFECTS 


also  called  mass  sutures  or  splint  sutures,  are  used  to  relieve  tension 
(relaxation  .futures),  and  to  obliterate  dead  si)aces  in  the  depths  of  a 
wound  in  which  it  is  not  desirable  to  leave  buried  sutures;  they  must 
be  strong  and  therefore  are  usually  of  non-absorbable  material. 
The  figure-of-eight  suture  (Fig.  110)  is  employed  by  some  surgeons 
as  a  deep  suture. 

Needles. — Straight  needles  are  most  generally  useful,  except  for 
inserting  buried  sutures,  for  which  curved  needles  are  to  be  preferred. 

Curved  needles  usually  are  held  in  a 
needle-holder  (Fig.  Ill),  but  straight 
needles  are  easily  managed  in  the 
fingers.  Ordinary  surgical  needles  are 
made  with  a  triangular  or  a  lance-shaped 


Fig.  111. — A  convenient  form  of 
needle-holder. 


•  A 


A  B 


•    C 


J) 


Fig.  112. — Various  forms  of  needles.  A, 
straight  round-pointed  needle.  B,  straight 
lance-pointed  needle.  C,  curved  round-pointed 
needle.     D,  curved  lance-pointed  needle. 


-point,  to  facilitate  their  introduction;  hwt  round  needles  (either  straight 
or  curved)  are  used  in  intestinal  work,  as  less  liable  to  cause  hemor- 
rhage or  to  allow  fecal  leakage  through  the  puncture  (Fig.  112).  The 
eye  of  a  needle  should  be  large  enough  to  be  threaded  easily  with  the 
suture  desired;  and  the  widest  part  of  the  needle  (belly)  should  be 


Fig.  113. — 1.  Reverdin's  needle,  showing  at  a  eye  opened,  at  h  eye  closed. 
2.  Ordinary  mounted  needle. 

situated  where  the  cutting  edges  ceases,  not  on  the  shaft  or  at  the  eye 
itself.  Special  forms  of  needles  are  set  in  handles,  and  have  the  eye 
near  the  point:  the  aneurysm  needle  (p.  232)  has  a  blunt  point,  and 
is  used  to  pass  ligatures  around  large  ^•essels;  the  ordinary  nioitnted 
needle  has  been  modified  b\-  lieverdin  by  inserting  a  slide  by  which  the 


SUTl'RES  AM)  KXOTS 


165 


eye  may  he  ojxmumI  to  facilitate  tlir('a(!iii<;'  ( l^'i^-    lli!),  and  is  useful 
ill  |)assiii^-  (leejr  sutures. 

Siifnrc  of  W  tin  mis.  Su[)erli(ial  woiiimIs  may  \)v  uuite(l  with  super- 
ficial sutures  (tuly;  if  the  deep  fascia  is  dixided,  it  should  he  united 
with  either  deep  or  l)uried  sutures,  as  the  suhsecpieut  strenj^th  of 
the  |)art  dej)ends  lar<iely  upon  the  accuracy  with  which  this  structure 
is  sutured,  and  e\eii  in  parts  where  strengtii  is  not  requisite  (us  in 

the  neck)  neglect  to  suture  the 
deeper  layers  carefully  results 
in  a  spreading  instead  of  a 
linear  cicatrix.  l)i\  ided  tendons, 
nerves,  etc.,  should  l)e  sutured 
separately  by  buried  sutures. 
In  extensive  wounds,  especially 
where  the  tissues  have  been 
much  bruised,  either  by  the  in- 
jury or  during  the  operation, 
it  usually  is  desirable  to  pro- 
vide for  drabuKje,  to  allow  the 


Fig.  114. — The  sriuaro  or  reef  knot,  uni- 
versally employed.  Note  that  correspond- 
ing ends  of  the  ligature  pass  under  (or 
over)  the  loop  of  the  knot. 


Fig.  115. — The  surgeon's  knot;  em- 
ployed rarely-,  hut  useful  if  the  first  hitoh 
of  the  knot  tends  to  slip  before  the  seeond 
can  be  pulled  tight.  The  same  as  the 
square  knot  exeejjt  that  the  first  hitch  is 
double. 


Fig.  116.— The  granny  knot.  Note  that 
of  corresponding  ends  of  the  ligature  one 
passes  over  and  the  other  under  the  loop 
of  the  knot. 


Fig.  117. — The  subcuticular  suture; 
it  may  be  used  if  no  dead  spaces  are  left 
in  the  deeper  parts  of  the  wound.  The 
needle  enters  the  true  skin  at  each  bite, 
not  merely  the  subcutaneous  tissues. 


escape  of  effused  blood,  lymph,  etc.,  which  would  retard  healing  if 
allowed  to  remain  l)etween  the  lips  of  the  wound,  and  perhaps 
cause  sloughing  from  pressure  if  not  evacuated.  Hence  the  im- 
portance of  accurate  hemostasis  in  all  wounds,  especially  where 
drainage  is  undesirable  (as  in  operations  for  radical  cure  of  hernia). 
Xo  dead  spaces  should  be  left  in  repairing  wounds:  they  will  be  filled 
by  blood-clot,  and  this  will  be  a  suitable  culture  medium  for  germs. 


1G6  INJURIES  AND  THEIR  EFFECTS 

Sutures  must  be  drawn  just  tight  enough  to  a])pose  the  edges  of 
the  wound  without  constricting  the  tissues.  Drawing  a  suture  too 
tight  may  break  it,  or  may  cause  sknighing  with  a  resulting  stitch 
sinus.  Sutures  are  secured  in  position  b\-  knots,  or  occasionally  by 
clam])ing  them  with  jjerforated  shot.  The  knot  employed  should 
be  one  that  will  not  slip,  especially  the  square  or  reef  knot  (Fig.  114), 
or  the  surgeons  knot  (Fig.  115),  never  the  granny  knot  (Fig.  116). 
Some  surgeons  employ  little  metal  clamps  (Michel)  to  appose  the 
skin  margins,  instead  of  sutures;  or  a  subcutlcnlar  suture  may  be 
used  (Fig.  117). 

Dressing  of  Incised  Wounds. — On  the  surface  of  nearly  every 
wound  there  will  be  a  slight  exudation  of  serum  between  the  sutures; 
to  prevent  the  dressings  from  sticking  to  the  wound  it  is  therefore 
well  to  cover  it  with  silver-foil,  or  to  dust  it  with  some  sterile  powder. 
Aseptic  wounds  may  be  dressed  with  aseptic  gauze,  that  next  the 
incision  being  crumpled  up  so  as  more  readily  to  absorb  any  dis- 
charges, while  the  outer  layers  of  gauze  are  applied  smoothly  and 
in  sufficient  thickness  and  width  to  protect  the  part  mechanically 
and  effectually  to  prevent  the  access  of  any  microbes  from  the  sur- 
rounding skin  or  from  the  fingers  of  the  patient  accidentally  inserted 
beneath  the  edges  of  the  dressing.  This  dressing  is  then  held  in 
place  by  strips  of  adhesive  plaster,  with  suitable  bandages,  splints, 
etc.,  as  required.  If  a  tube  or  a  wick  of  gauze  has  been  employed  for 
drainage,  the  dressings  are  to  be  so  arranged  that  the  discharges 
will  be  conducted  into  the  dressings  without  soiling  the  surface  of 
the  wound;  this  is  accomplished  by  carrying  the  drain  through  slits 
4n  the  dressing,  and  surrounding  its  outer  end  with  sufficient  crumpled 
gauze  to  absorb  the  anticipated  discharge;  and  carefully  protecting 
this  superficial  dressing  from  infection  by  sterile  absorbent  cotton 
or  more  gauze,  the  entire  dressing  being  suitably  bandaged  in  place. 
In  aseptic  incised  wounds  the  drain,  along  with  the  superficial  dressing, 
may  be  removed  at  the  end  of  twenty-four  or  forty-eight  hours, 
without  disturbing  the  deep  dressing.  In  infected  wounds  the  drains 
must  remain  until  their  tract  is  lined  with  granulations  (four  to  six 
days)  converting  it  into  a  sinus,  which  is  to  be  treated  according 
to  the  principles  already  discussed  (p.  52)  if  it  does  not  close  spon- 
taneously. Non-absorbable  sutures  are  to  be  removed  from  the 
sixth  to  the  tenth  day,  and  in  the  case  of  aseptic  incised  wounds  the 
dressing  need  not  be  changed  until  this  time  has  elapsed.  In  small 
wounds  of  the  face  superficial  sutures  occasionally  may  be  removed 
as  early  as  the  fourth  day,  but  in  the  case  of  a  larger  wound,  and 
especially  in  the  case  of  deep  or  relaxation  sutures,  it  is  unsafe  to 
remove  them  in  less  than  a  week  or  ten  days.  If  a  suture  is  found 
at  the  first  dressing  to  be  cutting  out,  it  should  be  removed,  trusting 
to  the  neighboring  stitches  to  maintain  the  lips  of  the  wound  in 
apposition;  and  frequently  it  is  safer  to  remove  only  alternate  stitches 
at  the  first  dressing,  and  leave  the  others  a  day  or  so  longer,  or  to 
support  the  wound  with  strips  of  sterile  adhesive  plaster  applied  at 
right  angles  to  its  surface. 


LACERATED   WOUNDS 


\iu 


Lacerated  and  Contused  Wounds.-  Lacerated  and  contused  wounds 
may  \)v  coiisidrrcd  toj^ctlicr,  as  they  are  j)r()dueed  by  the  same  acci- 
dents, and  usually  coexist.  In  lacerated  wounds  the  edges  are  torn, 
jagged,  and  irregular,  not  sharply  cut  as  in  the  case  of  incised  wounds; 
in  contused  wounds  the  lips  of  the  wound  and  the  surrounding  parts 
are  bruised  and  more  or  less  devitalized  by  the  original  injury.  Blows 
by  blunt  weapons  (clul)S,  stones,  etc.),  and  machinery  and  railroad 
accidents  are  the  principal  causes  of  contused  and  lacerated  wounds; 
owing  to  the  manner  of  their  production  they  are  almost  invariably 
infected,  from  bacteria  on  the  patient's  skin,  his  clothing,  or  on  the 
vulnerating  weapon.  Earth,  machine  oil,  cinders,  and  other  foreign 
matter  frequently  are  carried  into  the  depths  of  the  wound.  Gunshot 
wounds,  forming  a  special  variety  of  contused  wounds  are  considered 
in  Chapter  VII. 

Symptoms. — The  pain  of  contused  and  lacerated  wounds  is  less  sharp 
and  more  aching  than  in  the  case  of  incised  wounds;  hemorrhage  is 
less,  because  the  vessels  are  twisted  and  torn  off  rather  than  cleanly 
severed;  and  gaping  is  often  much  less  than  the  extent  of  the  injury 
would  lead  one  to  expect.  Shock  is  often  severe,  and  in  case  of  crush 
or  avulsion  of  a  limb  maj' 
cause  death  immediately 
or  so  soon  that  no  time 
is  afforded  for  local  reac- 
tion. This  reaction  in  the 
wounded  parts  frequenth' 
extends  to  the  stage  of  sup- 
puration, and  the  tissues 
are  so  much  devitalized 
that  more  or  less  sloughing 
is  the  rule. 

Treatment. — In  addition 
to  combating  shock  and 
checking  hemorrhage,  the 
surgeon  must  pay  particu- 
lar attention  to  cleansing 
the  wound.  Some  of  these 
injuries  are  so  severe  that 
nothing  less  than  amputa- 
tion will  save  life  (p.  192). 
But  in  lacerated  wounds 
or  crushes  of  the  hands, 
much  may  be  done  without 
amputation,  by  excision  of 
pulpefied  tissue  and  splinters  of  bone,  and  by  accurate  suture  of 
divided  tendons,  etc.  (Figs.  118,  119).  Occasionally  a  completely 
severed  finger  tip  will  grow  in  place  if  carefully  sutured.  General 
anesthesia  often  is  indicated  to  allow  the  necessary  treatment  to  be 
carried  out.     The  object  should   be  to  make  the  wound  approach 


Fig.  118. — Compound  fracture  of  metacarpals, 
by  circular  saw  injury.  Excision  of  heads  of  meta- 
carpals, and  suture  of  tendons.  Episcopal  Hospital. 


Fig.  119. — Same  patient  as  Fig.  118.    Earns  $3.50 
a  day,  working  as  carpenter. 


168 


INJURIES  AND   THEIR  EFFECTS 


ill  character  as  nearly  as  possible  to  an  aseptic  incised  wound.  The 
woniid,  itself,  is  first  packed  with  sterile  gauze.  Then  the  surround- 
ing skin  should  be  painted  with  3  per  cent,  iodin  solution,  and  if 
it  is  hairy  it  may  be  soaped  and  shaved  after  the  iodin  has  become 
thoroughly  dry.  If  it  is  not  hairy  it  is  sufficient  to  apply  a  second 
coat  of  the  iodin  solution  after  the  first  has  dried.  Then  foreign 
bodies  are  to  be  removed  from  the  face  of  the  wound,  slitting  up 
pockets  and  crannies  among  the  muscles  and  layers  of  fascia  if  neces- 
sary to  extract  bits  of  clothing,  coal  dust,  and  other  foreign  bodies. 
In  some  cases  the  filthy  structures  have  to  be  cut  bodily  away.  After 
the  wound  has  been  thus  mechanically  cleansed,  it  should  be  treated 

antiseptically,  being  swabbed  out  with 
gauze  soaked  in  iodin  solution.  I  have 
entirely  abandoned  the  use  of  cor- 
rosive sublimate  and  carbolic  acid  in 
such  cases,  as  I  find  strict  adherence 
to  the  iodin  technique  secures  better 
healing.  Hydrogen  peroxide  is  an- 
other efficient  antiseptic;  it  may  be 
applied  after  the  iodin,  but  more 
than  one  thorough  application  tends 
to  delay  healing.  In  all  cases  the 
cleansing  should  be  done  with  gen- 
tleness, it  being  an  excellent  maxim 
of  Sir  James  Paget's  that  "wounds 
should  not  be  scrubbed,  even  with 
sponges."  In  spite  of  the  utmost 
care  it  is  not  always  possible  to  en- 
sure freedom  from  infection  in  these 
wounds,  so  it  is  always  best  to  drain 
them,  using  only  sufficient  sutures 
to  hold  the  tissues  in  apposition  at 
the  extremities  of  the  wound.  Iiiter- 
rupted  sutures  always  are  to  be  pre- 
ferred to  continuous,  in  infected 
wounds,  since  one  or  more  can  be 
removed  at  any  time  to  relie^'e  ten- 
sion, without  destroying  the  entire 
suture  line.  Instead  of  aseptic  gauze  it  is  better  to  use  an  antiseptic 
dressing,  especially  of  gauze  soaked  in  equal  parts  of  alcohol  and 
corrosive  sublimate.  In  extensive  wounds,  where  sloughing  is  feared, 
it  is  well  to  pour  alcohol  over  the  dressings  every  few  hours,  so  as 
to  keep  them  moist.  Constant  irrigation  with  antiseptic  solutions 
is  often  of  great  value  (Fig.  120).  If  no  undue  rise  of  temperature 
or  local  pain  indicates  excessive  reaction  the  wound  need  not  be 
inspected  until  the  third  or  fourth  day;  and  if  then  the  surgeon  finds 
evidence  of  damming  up  of  secretions,  abscess  formation,  or  beginning 
cellulitis,  he    should    not    hesitate  to    remove    as    many  sutures  as 


Fig.  120.  —  Constant  irrigation 
for,  crushes,  contused  and  lacerated 
wounds,  etc.  ^The  solution  drips  over 
the  injured  part  by  gauze  syphonage. 
Episcopal  Hospital. 


PUNCTURED  WOUNDS 


169 


rc(iiiisitc  (all,  if  necessary),  and  pack  the  wouikI  lightly  with  anti- 
sej)tie  gauze,  using  drainage  tubes  as  indicated.  In  such  cases  the 
wound  gradually  becomes  converted  into  an  idccr,  and  should  be 
treati'd  accordingly. 

Punctured  Wounds.  I'nnctnrcd  wounds,  as  the  term  indicates, 
are  those  prodncetl  by  pointed  instruments,  and  their  imjjortance 
arises  from  the  fact  that  infection  (not  rarely  tetanus)  is  frequent, 
as  no  free  drainage  exists;  and  because  injury  to  deej)  structures 
(viscera,  joints,  nerv(>s,  etc.),  may  pass  uni)ercei\ed  at  first.  In 
ordinary  practice  punctured  wounds  are  produced  most  often  by 
needles,  nails,  hat  pins,  splinters,  umbrella  tii)s,  etc.  If  a  needle 
remains  in  place,  with  part  of  the  shaft  projecting  from  the  wound, 
it  should  be  extracted,  and   unless  known  to  be  serioush'  infected, 


Figs.  121  and  122. — Skiagraphs  to  localize  needle  in  palm  of  hand. 

it  is  sufficient  to  cleanse  the  surrounding  skin  and  apply  an  aseptic 
dressing.  In  a  patient  at  the  Episcopal  Hospital  a  hat  pin  which 
punctured  the  chest  produced  no  symptoms  of  any  kind,  though 
from  the  depth  and  direction  of  the  wound  it  is  certain  that  the 
liver,  diaphragm,  and  lung  were  all  traversed.  If  the  point  has  broken 
off  and  is  completely  buried  in  the  tissues,  an  immediate  attempt  to 
extract  it  should  be  made  if  its  position  can  be  detected  by  palpation; 
if  no  clue  as  to  its  location  exists  attempt  at  extraction  should  not 
be  made  until  it  has  been  accurately  located  by  the  use  of  the  .r-rays, 
two  exposures  in  planes  at  right  angles  to  each  other  being  made 
(Figs.  121  and  122).  The  incision,  for  which  local  anesthesia  some- 
times is  sufficient,  should  be  made  obliquely  to  the  course  of  the 
needle,  being  thus  more  apt  to  strike  it  than  if  made  parallel.    A 


170  INJURIES  AND   THEIR  EFFECTS 

needle  buried  in  the  palm  is  best  exposed  by  turin'nfi;  uj^  a  flap  of 
skin.  If  a  large  joint  has  been  punctured,  the  part  should  be  immo- 
l)ilized,  the  patient  being  kept  in  bed  if  necessary.  In  wounds  from 
splinters  and  rusty  nails  the  danger  of  tetanus  developing  is  greater; 
accordingly  the  ])uncture  should  be  slit  up,  to  ensure  the  removal  of 
all  parts  of  the  splinter,  and  to  allow  the  application  of  antiseptics 
to  all  parts  of  the  wound. 

Stab  wounds  occasionally  are  seen  in  cWW  practice;  they  partake 
of  the  nature  of  both  incised  and  punctured  wounds,  and  like  the 
latter  are  of  interest  chiefly  from  the  implication  of  joints,  internal 
organs,  bloodvessels,  nerves,  etc.  Their  treatment  is  considered 
in  the  chapter  dealing  with  the  surgery  of  these  structures.  Bayonet 
wounds  are  seldom  seen  nowadays,  even  in  military  surgery.  In 
battles  with  Indians  and  other  uncivilized  tribes  arrow  wounds  are 
sometimes  encountered.  The  arrow-head  is  very  easily  detached 
from  the  shaft,  and  reckless  attempts  to  extract  the  weapon  frequently 
result  in  the  head  breaking  ofY  and  remaining  in  the  tissues  as  a  foreign 
body.  Sometimes  it  is  better  to  push  the  arrow  on  and  extract  it 
through  the  counterpuncture.  Indian  arrows'  were  frequently 
poisoned  with  rattlesnake  venom  or  with  earth  containing  tetanus 
germs,  and  Schell  found  it  a  universal  custom  to  dip  the  points  in 
blood  which  was  allowed  to  dry  on  them;  but  such  practices  are 
rare  at  the  present  day. 

Tooth  wounds,  especially  those  due  to  human  bites,  are  apt  to  be 
severely  infected.  Dog  bites  are  less  dangerous  than  those  of  cats, 
rats,  and  other  domestic  animals.  Monkey  and  parrot  bites  are  not 
very  rare.     I  have  treated  a  case  of  mole  bite. 

Poisoned  Wounds. — Under  this  heading  it  is  convenient  to  consider 
snake  bites  and  insect-stings.  The  latter  are  seldom  serious  in  this 
part  of  the  country,  but  in  the  tropics  are  sometimes  fatal.  The 
lesion  consists  in  a  localized,  occasionally  a  spreading  cellulitis, 
which  is  treated  by  evaporating  and  antiseptic  lotions.  The  pain 
of  stings  is  quickly  allayed  l)y  plastering  the  bite  with  liquid  mud, 
which  should  be  washed  off  so  soon  as  antiseptics  are  available; 
aqua  ammonise  also  relieves  the  pain  and  neutralizes  the  acid  poison, 

S7ial-e  Bites. — Snakes  (ophidia)  are  divided  into  two  main  classes, 
the  Colubrines,  mostly  harmless,  and  the  Viperines,  usually  poisonous 
(thauatophidia — death-suakes).  To  know  whether  the  injury  is  from 
a  harmless  or  a  poisonous  snake,  the  bite  should  be  examined:  "If 
the  snake  is  harmless,  two  uniform  rows  of  tooth  marks  will  be  found; 
if  there  are  two  or  more  distinct  fang-marks,  with  or  without  tooth- 
marks,  the  snake  is  poisonous"  (Fig.  123)  (Mason,  1907).  The 
venom  is  contained  in  a  sac  at  the  base  of  the  hollow  fang,  which  is 
on  the  upper  jaw;  this  sac  is  compressed  by  the  muscles  which  close 
the  jaws,  and  the  virus  is  squirted  through  the  hollow  fang  much 
as  through  a  hypodermic  needle.  Repeated  biting  soon  empties 
the  poison  sac,  and  the  snake  is  then  comparatively  harmless  until 
more  virus  has  been  secreted. 


POISONED   WOUNDS  171 

The  most  iniportaiit  coiistituciits  of  snake  venom  are  a  glol)uliii 
aixl  a  peptone.  Tlie  former  destroys  the  coagulability  of  the  l)loo(l, 
and  pnxhiees  moleeiilar  changes  in  the  vessel  walls;  this  accounts 
for  the  extra\asation  and  hemorrhages  (subcutaneous,  gastro- 
intestinal, renal),  which  are  characteristic  of  snake  poisoning.  The 
j)eptone  produces  locally  "rapid 
edema.        i)utrefaction,        and 

sloughing    without    extravasa-      /  /    \  •.  •   .•  "■   * 

tion;     constitutionally,     it    in-      /   :       •.    ".  •  .'     '; 

creases  blood-i)ressure,  acceler-     I    '■        :    •  '•[  •  .     .  • 

ates  the  respiration,  and  often      ;    ".       ;"    :  •.      :  \     '• 

causes    convulsions."     (Mason,      •    ".      •  •.    :  \    \ 

1907.)      In    rattlesnake     bites,       •    :    :    ■  •    ;  •    ; 

almost  the  only   kind  seen   in  •     \  .•    "•.  •    ; 

this   country,   death   occurs   in  •       •  '       ' 

from  12  to  25  per  cent,  of  cases,  Fiq.  123.— Tooth  marks   made   by   snake 

USUallv     within    twenty-four    to  bites:  on  the    left  a    harmless    snake;    fang- 

,  .        "^    .        ,                    TA      ii       i>  marks  in   the  centre  and  on    the  right    indi- 

thirty-SlX     hours.       Death     irom  cate  a  poisonous  snake. 

cobra  bites,  which  are  frequent 

in  India,  and  not  very  rare  in  the  PhiUppines,  occurs  usually  in  a  few 
hours.  Bites  of  copper-heads  and  moccasins  are  not  so  fatal,  though 
amputation  may  be  required  for  sloughing,  or  septicemia  may  kill 
at  a  later  date. 

Treatment  consists,  locally,  in  the  immediate  application  of  a 
ligature  or  tourniquet  around  the  limb  above  the  wound,  and  in 
suction  of  the  punctures  by  the  mouth,  or  by  cupping  glasses  when 
available.  The  venom  is  not  poisonous  when  taken  by  mouth,  if 
the  stomach  is  full;  but  it  should  of  course  be  spat  out.  Free  incisions 
will  make  suction  more  effective.  Amputation  or  excision  of  an 
unimportant  part  may  be  done.  The  ligature  should  be  used  inter- 
mittently, admitting  only  small  doses  of  the  venom  into  the  circula- 
tion at  one  time;  and  when  the  wound  is  far  enough  from  the  trunk 
to  make  it  possible,  it  is  well  to  apply  a  high  and  a  low  ligature 
alternately.  Mason  also  recommends  that  the  limb  be  bandaged 
from  its  two  extremities  toward  the  wound,  so  as  to  squeeze  out  all 
the  venon  possible.  The  best  local  applications  after  free  incision 
are  oxidizing  agents,  such  as  peroxide  of  hydrogen,  or  1  per  cent, 
solutions  of  potassium  permanganate  or  chromic  acid.  The  actual 
cautery  (hot  coals,  burning  gun-powder)  should  be  employed  if  these 
remedies  are  not  at  hand.  Local  treatment  should  be  prompt,  as  it 
is  probably  useless  after  the  lapse  of  half  an  hour.  Constitutionally 
alcoholic  stimulants  are  indicated,  being  pushed  to  the  point  just 
short  of  intoxication.  Strychnin  is  considered  valuable.  Calmette's 
serum  (antivenene)  should  always  be  employed  when  available; 
hypodermic  injections  of  10  to  20  c.c.  of  the  stronger  serum  are 
given  as  soon  as  possible.  Gastric  lavage  and  catharsis  are  indicated 
to  remove  the  venom  excreted  into  the  gastro-intestinal  tract.  Hope 
should  not  be  abandoned  too  soon,  some  remarkable  recoveries  being 
recorded  after  the  prolonged  use  of  artificial  respiration. 


172  INJURIES  AND  THEIR  EFFECTS 

GENERAL  EFFECTS  OF  INJURIES. 

Shock. — The  immediate  constitutional  effect  of  injury  is  named 
shock.  A  se^'e^e  grade  of  sliock  is  called  coUapse.  Altliough  no  \ery 
accurate  knowledge  of  the  pathogenesis  of  shock  has  yet  ))een  o})tained, 
in  spite  of  the  elaborate  experimental  investigations  of  Crile  (1899), 
and  others,  it  is  certain  that  its  most  important  features  are  due  to 
interference  with  the  vaso-motor  mechanism,  resulting  in  marked 
jail  of  hlood-y  res  sure.  The  action  on  the  vaso-motor  centre  takes 
place  through  the  nerves  supplying  the  injured  part,  and  injuries 
of  regions  endowed  with  more  highly  specialized  nerves  are  more  apt 
to  produce  shock  than  injuries  of  other  parts.  Severe,  even  fatal, 
shock  occasionally  follows  injuries  accompanied  by  insignificant 
traumatism  to  the  body  tissues.  Shock  is  especially  apt  to  occur 
from  injuries  of  the  larynx,  and  of  the  viscera,  particularly  those  of 
the  upper  abdomen,  involving  the  splanchnic,  and  those  of  the  thorax 
involving  the  cardiac  plexuses.  Injuries  of  the  genitalia  are  frequently 
accompanied  b}'  marked  shock,  when  the  nerves  of  the  spermatic 
cord  are  bruised  or  injured.  Extensive  burns  and  scalds,  affecting 
immense  numbers  of  peripheral  nerve  endings,  are  followed  by  marked 
shock.  Lacerated  and  contused  wounds,  gunshot  wounds,  mangling 
injuries,  and  crushes  are  often  accompanied  by  an  extraordinary 
degree  of  shock.  Henderson  (1908)  has  proposed  the  theory  that 
shock  is  due  chiefly  to  loss  of  the  carbon  dioxide  constituent  of  the 
blood,  a  state  to  which  he  applies  the  term  acapnia;  and  as  carbon 
dioxide  is  a  W'cU  known  stimulant  of  the  pressor  mechanism  of  the 
vaso-motor  system,  causing  rise  of  blood-pressure,  it  is  not  improbable 
that  the  shock  which  follows  eventration  of  the  intestines  in  certain 
operations  may  be  partly  accounted  for  in  this  way. 

Predisposing  Causes. — General  debility,  extreme  youth  and  age, 
and  organic  disease  of  the  heart,  kidneys,  or  other  viscera,  are  among 
the  predisposing  causes.  Exposure  and  chilling  of  the  body  surface, 
if  prolonged,  will  increase  shock.  Hemorrhage,  by  directly  affecting 
the  patient's  vitality,  and  lowering  blood-pressure,  is  probably  the 
most  important  cause  of  all.  Prolonged  anesthetization  acts  in  a 
similar  manner,  chloroform  causing  lowering  of  blood-pressure  from 
the  very  first,  ether  only  after  long  administration. 

Symptoms. — The  patient,  if  not  stunned  by  the  injury  or  suffering 
from  cerebral  concussion,  is  conscious,  his  mind  sometimes  being 
clear  and  alert,  but  more  often  semi-stuporous,  as  if  the  effort  even  to 
think  were  exhausting.  The  face  is  pale,  the  lips  ashen  or  slightly 
blue;  the  entire  body  surface  is  pale,  cold,  and  often  clammy;  the 
temperature  is  subnormal  (Fig.  124);  the  eyes  are  staring  or  half- 
closed;  there  may  be  dimness  of  vision  or  actual  blindness  (from 
retinal  anemia);  the  pupils  are  dilated,  and  react  sluggishly  to  light; 
the  respirations  are  shallow  and  rapid;  the  pulse  is  quick,  fluttering, 
weak  and  frequently  uncountable.  Incontinence  of  feces  is  frequent, 
that  of  urine  rare  and  usually  portends  a  fatal  issue.     The  patient 


SHOCK 


173 


DAY  OF 
MONTH 

5    0 

!- 1  'l>  t 

7                8 

UK] 

I 

<  '.)•.) 

< 

tii; 

'Jo 

J 

^1- 

Fig.  124. — Shock  and  reac- 
tion. Case  of  multiple  frac- 
tures; man,  aged  thirty  years. 
Episcopal  Hospital. 


lies  inotioiilrss  wluTcver  plac<'<l.  This  torpid  .sinf/r  may  last  a  few 
minutes  or  several  days.  Death  may  oecur  without  reaction,  in 
spite  of  energetic  treatment.  If  reaction  occurs,  the  patient  usually 
sighs  deeply,  m()\'es  his  eyes  and  limbs  voluntarily,  and  turns  on 
his  side;  vomiting  is  not  an  muisual  sequel.  Ueeo\ery  may  be  aj)[)ar- 
ently  comi)lete  in  a  few  minutes,  or  may 
occur  gradually,  especially  when  there  is 
some  severe  injury  present.  When  reaction 
occurs,  it  may  be  excessive,  the  ])atient  be- 
coming mildly  delirious,  and  exhibiting  the 
condition  described  by  Travers  (1827)  as 
prostration  with  excitement  (erethistic  shock). 
This  condition,  which  occasionally  develops 
immediately  after  the  injury,  the  torpid  stage 
being  extremely  short  or  altogether  absent, 
may  pass  into  true  traumatic  deliri^im,  an 
affection  probably  due  to  some  form  of 
toxemia.  The  patient  is  restless,  talkative, 
with  bright,  roving  eyes  and  incessant  action ; 
he  is  really  weak,  though  seemingly  strong, 

and  is  liable  to  collapse  at  any  time.  He  is  pursued  by  frightful 
hallucinations,  often  acting  over  and  over  again  in  his  delirium  the 
drama  of  his  injury.  Traumatic  delirium  should  always  be  regarded 
as  a  dangerous  complication,  being  unusually  serious  when  develop- 
ing immediately  after  the  accident. 

After  death  from  shock  there  may  be  found  no  lesions  sufficient 
to  have  caused  death.  In  such  cases  death  probably  has  occurred 
from  inhibition  of  the  heart's  action  (collapse.)  Usually,  however, 
the  venous  system  is  found  to  be  filled  with  blood,  the  capillaries 
and  arteries  being  comparatively  empty,  and  the  great  bulk  of  the 
blood  being  contained  in  the  portal  system  of  veins  and  the  vena 
ca\'a :  it  is  as  if  the  patient  had  bled  to  death  intravenously.  Evidently 
the  heart  has  ceased  to  act  because  no  blood  was  supplied  for  it  to 
contract  upon,  the  coronary  as  well  as  the  systemic  arteries  being 
thus  deprived  of  blood. 

Under  the  name  of  secondary  or  insidious  shock  has  long  been 
described  a  change,  almost  invariably  fatal,  usually  occurring  a 
day  or  so  after  apparent  recovery  from  the  primary  shock  of  an 
injury  or  operation.  At  autopsy  the  right  heart  is  found  distended 
with  clots,  which  may  invade  the  pulmonary  arteries,  constituting 
pulmonary  embolism  (p.  178).  It  is  probable  that  most  such  cases 
are  caused  by  a  low  grade  of  sepsis. 

Diagnosis. — To  differentiate  shock  from  internal  hemorrhage  is 
frequently  impossible  until  the  physical  signs  of  the  effused  blood 
appear;  moreover,  in  any  case  of  extensive  hemorrhage,  shock  will 
be  present  also.  Syncope  occurs  without  history  of  injury,  the  patient 
becoming  unconscious,  and  possibly  being  subject  to  fainting  fits. 
Psychical  shock  (fright)  should  not  be  mistaken  for  surgical  shock; 


174  INJURIES  AND   THEIR  EFFECTS 

it  may  result  in  death  in  the  absence  of  all  injury,  especially  in  cardiac 
patients,  but  usually  the  mental  trepidation  soon  passes  off,  having 
caused  no  more  serious  disturbance  than  a  sinking  feeling  in  the 
l)recordium,  slight  qualmishness,  and  a  temporarily  accelerated 
pulse.  Erethistic  shock  and  traumatic  delirium  are  to  be  distinguished 
from  delirium  tremens  and  mania  a  potu.  In  these  a  history  of  chronic 
alcoholism  usually  can  be  obtained,  and  the  delirium  is  somewhat 
different  in  character:  in  delirium  tremens  which  may  be  regarded 
as  the  first  stage  of  the  affection,  the  patient  is  fearful  and  shrinking, 
the  delirium  is  muttering,  the  hallucinations  usually  relate  to  insects, 
reptiles,  etc.,  and  the  trembling  of  the  hands  is  characteristic;  in 
mania  a  potu,  the  second  stage,  he  is  violent,  shouting,  cursing  and 
singing,  with  no  fear  of  man  or  devil,  breaking  loose  from  the  bed, 
attempting  to  climb  out  of  the  window,  and  having  no  sensations 
of  the  pains  caused  himself,  grinding  his  broken  bones  together  as 
if  they  were  cobble-stones  (Hunt,  1881),  and  sometimes  wilfully 
mutilating  his  person.  Yet  as  alcoholics  are  prone  to  severe  injury, 
and  therefore  to  shock,  it  is  frequently  impossible  to  say  whether 
the  ensuing  delirium  is  alcoholic  or  purely  traumatic.  The  delirium  of 
uremic  conditions  (Chapter  XXV)  adds  another  confusing  factor  which 
is  often  present  in  injured  alcoholics  and  others  with  diseased  kidneys. 

Prevention  of  Shock. — General  anesthesia  does  not  prevent  shock. 
Ether  is  a  cardiac  stimulant,  and  when  first  administered  by  inhalation 
or  hypodermically,  will  increase  the  force  of  the  heart  beat,  and  in 
this  way  may  make  the  shock  less  than  it  would  have  been  otherwise ; 
but  if  long  continued,  the  blood-pressure  falls;  and  shock  is  increased. 
Unconsciousness,  however,  almost  invariably  diminishes  the  shock 
of  an  operation.  The  peripheral  nerve  trunks  may  be  blocked  by 
injecting  them  with  cocain,  thus  cutting  off  impulses  of  all  kinds 
which  might  reach  the  vaso-motor  centre  (anoci-association,  p.  148); 
in  this  way  operative  shock  may  be  so  prevented,  that,  as  Crile  says, 
after  cocainizing  the  nerve  trunks  and  ligating  the  main  vessels, 
an  amputation  may  be  done  with  no  more  effect  on  the  patient  than 
would  be  produced  by  cutting  the  sleeve  oft'  his  coat.  The  hypodermic 
use  of  atropin  is  valuable  in  two  ways:  it  causes  a  rise  of  blood- 
pressure  by  central  action,  and  by  paralyzing  the  inhibitory  fibres 
of  the  vagus  prevents  injurious  impulses  from  reaching  the  heart 
and  producing  collapse.  Cocain  hypodermically  acts  much  in  the 
same  way.  Morphin  is  less  efficient,  and  strychnin  is  practically 
worthless  except  as  a  tonic  administered  for  some  days  in  advance  of 
operation. 

During  an  operation  the  most  important  means  of  preventing 
shock  are  control  of  bleeding,  gentle  manipulation,  and  maintenance 
of  bodily  heat.  Direct  trauma  to  the  tissues,  especially  nerves, 
should  be  studiously  avoided;  direct  division  by  the  scalpel  should 
replace  blunt  dissection  and  tearing,  dragging  manipulations  when- 
ever possible.  Mechanical  means  for  maintaining  blood-pressure 
are  discussed  under  Treatment. 


SHOCK  '  175 

Treatment.  'V\w  iiidications  are  to  restore  blood-pressure,  ])revent 
the  loss  of  l)o(ly  heat,  and  keep  the  patient  alive  (by  artificial  respira- 
tion if  necessary)  until  the  remedies  used  have  time  to  act.  Bleeding 
must  be  checked  by  pressure,  elevation,  tourniciuet,  ligatures,  etc.; 
the  patient's  head  should  be  lowered  to  allow  the  blood  to  flow  into 
the  empty  heart.  Cover  the  patient  warmly,  and  surround  him  with 
hot  water  bottles,  hot  bricks,  etc.;  give  him  atropin,  digitalis,  or 
adrenalin,  hypodcnnically;  encase  his  extremities  in  raw  cotton, 
and  bandage  them  from  the  periphery  toward  the  trunk  (mitotrans- 
fiision),  thus  forcing  blood  to  the  heart;  perform  artificial  respiration 
and  apply  massage  to  the  heart  by  direct  pressure  over  the  precordium, 
or  transdiaphragmatically  through  an  epigastric  incision.  Give 
saline  solution  intra\'enously,  and  in  severe  cases,  and  where  facilities 
exist,  do  direct  transfusion.  Adrenalin  may  be  added  to  the  saline 
solution  (1  to  20,000). 

Great  care  should  be  taken  to  be  sure  that  serious  symptoms 
occurring  during  an  operation  are  really  due  to  shock,  and  not  to 
acute  dilatation  of  the  heart.  In  the  latter  condition,  the  measures 
above  detailed  for  driving  more  blood  into  the  right  heart  wall  only 
make  matters  worse:  the  head  should  be  kept  high,  and,  if  this  does 
not  relieve,  the  patient  should  be  bled,  and  in  extreme  cases  the  right 
ventricle  may  be  punctured.  In  any  case,  artificial  respiration  and 
massage  of  the  heart  should  be  persisted  in  for  fifteen  or  twenty 
minutes. 

In  shock  from  inhibition,  as  in  operations  on  the  larynx  and  thoracic 
organs,  the  most  important  measures  are:  the  head-low  posture 
with  artificial  respiration  and  cardiac  massage,  both  secured  by 
"rapid  rhythmic  pressure  upon  the  thorax  over  the  heart"  (Crile), 
with  the  tongue  drawn  well  forward  and  upward,  to  open  the  larynx. 
In  shock  due  primarily  to  hemorrhage,  the  head-down  posture,  the 
use  of  saline  solution,  and  bandaging  the  extremities  are  of  most 
value.  In  the  severest  cases  of  shock,  with  cessation  of  respiration 
and  circulation  (suspended  animation),  adrenalin  should  be  added 
to  the  saline  solution,  injecting  10  to  30  minims  of  a  1  to  1000  solu- 
tion of  adrenalin  chloride,  drop  by  drop,  from  a  hypodermic  syringe, 
into  the  rubber  tube  through  which  the  saline  solution  runs,  the 
entire  amount  being  administered  in  about  one  minute  (Crile). 
Cardiac  massage  will  force  enough  of  the  adrenalin  saline  solution 
into  the  arterial  system  to  raise  the  blood-pressure  enough  to  sustain 
the  circulation.  In  conjunction  with  the  other  methods  detailed 
above,  this  may  bring  back  the  dead  to  life.  If  relapse  follows  tem- 
porary improvement,  more  adrenalin  should  be  used,  as  its  effect 
is  evanescent. 

Treatment  of  Traumatic  Deliriimi  and  Delirium  Tremens. — If  the 
patient  is  not  too  violent,  attempts  should  be  made  to  dilute  the 
toxins  in  the  blood  by  the  use  of  saline  solution,  by  rectum,  hypoder- 
mically,  or  even  intravenously.  Lumbar  puncture  sometimes  aborts 
the  disease.    In  any  case  the  patient  should  be  isolated,  to  avoid  the 


176  INJURIES  AND   THEIR  EFFECTS 

mutually  exciting  effect  of  other  patients.  Catharsis  will  aid  elimi- 
nation of  toxins.  Sedatives  and  hypnotics  should  be  freely  employed, 
especially  veronal,  and  paraldehyde.  Sleep  should  be  obtained  at 
all  hazards,  but  m()r])hin,  hyoscin,  chloral,  and  the  bromides  increase 
the  mortality,  and  arc  much  less  effective  than  veronal  and  paralde- 
hyde (Ranson  and  Scott,  1911).  Measures  must  be  taken  to  prevent 
the  patient  from  injuring  himself,  strapping  him  to  the  bed  if  necessary, 
and  never  leaving  him  unguarded  by  a  nurse  or  orderly  strong  enough 
to  control  his  actions.  Liquid  diet  should  be  taken  in  moderation, 
but  the  more  water  that  can  be  absorbed  the  better.  Ranson  and 
Scott  urge  the  use  of  ergot  (1  dram  of  fluidextract  every  four 
hours)  as  preventative  of  cerebral  edema  and  as  a  general  circulatory 
stimulant.  No  alcohol  should  be  given  to  patients  ^^'ith  alcoholic 
delirium;  though  Ranson  and  Scott  urge  its  administration  at  least 
in  the  first  stage  of  the  affection,  all  surgeons  of  large  experience  in 
accident  w^ards  find  that  immediate  and  absolute  icithdrawal  of  alcohol 
from  patients  with  delirium  tremens  both  shortens  the  disease  and 
decreases  the  mortality.  In  traumatic  delirium  from  burns,  etc., 
in  which  there  is  clear  evidence  that  no  element  of  delirium  tremens 
is  present,  but  in  which  delirium  is  due  chiefly  to  asthenia,  the 
moderate  use  of  alcohol  frequently  hastens  convalescence. 

Causes  of  Death  after  Operation. — As  operations  always  involve 
the  infliction  of  wounds,  this  seems  a  suitable  place  to  consider  the 
causes  of  death  after  operation.  Certain  of  these  causes  are  more  or 
less  avoidable;  such  are  shock,  hemorrhage,  pneumonia,  and  sepsis. 
Others  usually  seem  unavoidable,  especially  myocarditis,  embolism, 
status  lymphaticus,  heat  prostration,  and  conditions  previously 
present  which  the  operation  could  not  remove  or  which  it  has  inevit- 
ably made  worse.  Among  the  latter  may  be  mentioned  various  forms 
of  sepsis  (peritonitis,  pyemia,  etc.),  curable  only  by  removal  of  the 
original  focus  and  the  institution  of  drainage,  but  which  these  meas- 
ures, though  judiciously  and  skilfully  executed,  nevertheless  fail  to 
relieve;  asthenia  from  preexisting  shock  or  hemorrhage,  death  being 
certain  without  operation,  but  a  fighting  chance  of  recovery  existing 
after  prompt  operation;  and  preexisting  disease  of  the  kidneys  or 
other  organs  when  operation  is  undertaken  as  the  only  means  of 
cure.  The  conscientious  surgeon  will  never,  therefore,  blithely  assure 
his  patient  that  any  operation  is  entirely  devoid  of  risk,  as  these 
calamitous  deaths  frequently  occur  when  least  expected. 

Shock. — See  p.  172. 

Hemorrhage. — The  importance  of  preventing  loss  of  blood  during 
operations  cannot  be  overestimated;  and,  fortunately,  gross  and 
sudden  hemorrhages  usually  can  be  prevented,  for  it  is  these  which 
are  much  more  lethal  than  the  slight  ooze  throughout  the  operation 
which  sometimes  is  unavoidable.  But  even  though  quite  large 
amounts  of  blood  may  be  lost  gradually  without  producing  immediate 
and  noticeable  effects,  it  is  much  better  for  the  surgeon  to  go  about 
his  work  deliberately,  clamping  or  tying  bleeding  vessels  as  he  goes, 


CAUSES  OF   DEATH   AFTER  Ol'EHATIOS  177 

than  to  try  to  hurry  aloii^  and  by  liis  very  haste  niakiiiji:  less  speed 
from  ha\iii<:  continually  to  return  and  pick  up  vessels  whieh  niij^ht 
have  heen  eau^dit  with  more  ett'eet  when  first  divided,  and  thus 
subject  his  ])atient  not  only  to  the  unnecessary  if  gradual  loss  of 
blood,  but  also  to  a  needlessly  j)rolonged  operation,  and  to  unneces- 
sary tissue  traumatism  from  rej)eated  sponging  and  search  for  the 
bleeding  points. 

In  addition  to  this  primary  hemorrhage  which  occurs  at  the  time  of 
operation,  surgeons  recognize  an  intermediary,  consecuti\e,  or  reac- 
tionarii  hemorrhage,  which  occurs  after  recovery  from  the  anesthetic 
or  the  shock  of  operation,  due  to  the  reestablishment  of  the  normal 
circulation  and  blood-pressure,  causing  bleeding  from  vessels  which 
escaped  notice  at  the  time  of  operation  owing  to  their  collapsed 
condition;  and  a  seeondarii  hemorrhage,  which  occurs  any  time  between 
the  occurrence  of  reaction  and  the  ultimate  healing  of  the  wound. 
Secondary  hemorrhage  is  due  usually  to  separation  of  ligatures 
(1)  from  their  having  been  insecurely  applied  at  first;  (2)  to  their 
premature  absorption;  or  (3)  to  ulceration  of  the  vessel  walls  at  the 
site  of  ligation;  occasionally  it  is  due  (4)  to  sloughing  of  a  vessel  at 
another  point  in  the  wound. 

The  treatment  of  hemorrhage  is  discussed  at  p.  228. 

Pneumonia. — Careful  examination  of  the  lungs  should  always  be 
made  before  undertaking  any  operation,  especially  under  a  general 
anesthetic.  If  bronchitis  or  pneumonia  already  exists  and  the  oper- 
ation cannot  possibly  be  postponed,  as  in  the  case  of  strangulated 
hernia,  local  or  spinal  anesthesia  should  be  employed.  To  prevent 
the  development  of  pulmonary  complications,  a  general  anesthetic 
must  be  given  with  care,  guarding  against  choking,  secretion  of  mucus, 
and  inspiration  of  vomited  particles;  and  pains  must  be  taken  not  to 
expose  the  patient  to  chilling,  draughts,  etc.,  either  during  operation 
or  while  recovering  from  the  anesthetic.  After  an  operation,  patients, 
especially  if  aged,  should  not  be  kept  flat  on  the  back  long,  being 
turned  from  side  to  side  at  suitable  intervals  to  guard  against  the 
development  of  hypostatic  congestion;  deep  breathing  should  be 
enjoined  periodically;  and  they  should  be  allowed  to  sit  up  or  to 
leave  the  bed  so  soon  as  the  condition  of  the  wound  permits. 

Sepsis. — In  operations  on  previously  aseptic  structures,  sepsis  can 
and  should  be  prevented.  Whenever  it  occurs  under  such  circum- 
stances, the  surgeon  should  seriously  endeavor  to  detect  the  fault 
in  his  technique,  in  order  that  a  similar  calamity  may  not  occur 
again.  In  operations  on  already  infected  parts,  it  will  not  always 
be  possible  to  prevent  infection  from  spreading  further,  or  from 
becoming  more  virulent  even  if  still  localized;  but  by  strict  adherence 
to  antiseptic  methods,  unfavorable  results  might  be  made  much  less 
frecjuent  than  they  are. 

Myocarditis. — "Heart  failure"  usually  is  an  una\oidabIe  cause  of 
death;  detection  of  the  lesion  before  operation  is  frequently  difficult, 
and  even  skilled  physicians  occasionally  err  in  estimating  the  ability 
12  '  ' 


178  INJURIES  AND   THEIR  EFFECTS 

of  an  evidently  diseased  heart  to  withstand  the  strain  of  operation. 
The  choice  of  anesthetic,  the  position  of  the  patient  during  operation, 
avoidance  of  causes  of  cardiac  collapse  and  of  shock,  the  rapidity 
and  extent  of  the  operation  itself,  all  deserve  to  be  considered  more 
attentively  than  usual  in  such  patients. 

Embolism. — Under  the  term  "secondary  or  insidious  shock"  (p. 
173 J  was  formerly  described  a  condition  which  is  now  popularly 
known  as  "pulmonary  embolism."  From  some  chemical  change 
(bacterial  or  aseptic)  in  the  blood,  it  becomes  more  prone  to  clot, 
and  at  various  periods  after  operation,  but  usually  not  until  con- 
valescence seems  assured,  a  portion  of  a  thrombus,  formed  at  or  near 
the  seat  of  operation,  is  detached,  is  carried  to  the  right  heart,  and 
thence  to  the  pulmonary  arteries,  where  it  may  lodge;  or,  passing 
through,  may  cause  pulmonary  infarction.  The  symptoms  are  sudden 
dyspnea,  cyanosis,  precordial  pain,  collapse,  and  rapid,  perhaps 
immediate,  death.  Busch  (1909)  has  recently  studied  twenty-two 
deaths  after  operation,  presenting  symptoms  usually  ascribed  to 
pulmonary  embolism :  twelve  of  these  patients  died  with  great  sudden- 
ness, no  preliminary  symptoms  of  any  kind  existing;  while  in  ten 
death  occurred  at  periods  varying  from  ten  minutes  to  three  and 
one-half  hours  after  onset  of  the  symptoms.  These  ten  patients 
all  came  to  autopsy,  and  in  only  five  was  a  pulmonary  embolus  or 
infarction  found,  the  five  others  having  died  from  myocarditis.  The 
diagnosis,  therefore,  is  not  always  easy. 

Treatment.  —  The  treatment  is  purely  symptomatic,  including 
inhalations  of  ammonia,  and  the  hypodermic  use  of  atropin,  oil  of 
camphor,  etc.  Trendelenburg  (1908)  has  proposed  arteriotomy  of 
the  pulmonary  artery,  by  opening  the  pericardium,  with  removal 
of  the  clot;  he  adopted  the  operation  in  one  case,  his  patient  living 
until  the  next  day,  while  Siever's  patient  (1908)  lived  fifteen  hours. 
As  death  frequently  occurs  with  great  suddenness,  giving  no  oppor- 
tunity for  treatment  of  any  kind;  and  as  in  other  cases  recovery 
under  expectant  treatment,  though  rare,  is  not  unknown;  and  as  the 
diagnosis  between  myocarditis  and  embolism  is  often  impossible,  I 
think  Trendelenburg's  operation  should  be  regarded  at  present  more 
in  the  light  of  interesting  surgical  gymnastics  than  as  a  practice  for 
habitual  employment. 

Fat-embolism. — Fat-embolism  occasionally  occurs  after  injuries  of 
or  operations  on  bones.  The  symptoms  and  treatment  resemble 
those  of  ordinary  pulmonary  embolism;  lipuria  is  not  pathogno- 
monic, though  suggestive,  and  it  may  exist  in  cases  of  simple  fracture 
without  evidence  of  embolism. 

Status  Lymphaticus. — This  term  is  used  to  describe  a  condition 
in  which  there  exists  widespread  enlargement  of  lymphoid  tissue 
in  all  portions  of  the  body — naso-pharyngeal  "adenoids,"  cervical 
"adenitis,"  hypertrophy  or  hyperplasia  of  the  bronchial  and  mesen- 
teric lymph  nodes,  and  of  the  thymus  gland.  It  is  most  frequent 
in  rachitic  children,  and  subjects  of  it  are  liable  to  sudden  death  at 


CAUSES  OF  DEATH   AFTER  OF E RAT  10 X 


179 


any  time,  even  diirins  natural  sleep  (Blumer,  1903).  The  true  cause 
of  these  deaths  is  not  known,  but  is  probably  to  be  classed  as  an 
"auto-intoxication;"  death  almost  certainly  is  not  due  to  acute 
enlargement  of  the  thymus  gland  causing  asphyxia  from  pressure 
on  the  trachea.  Unfortunately  the  existence  of  the  condition  is 
rarely  if  ever  recognized  until  death  occurs.  Undoubtedly  some 
deaths  charged  to  the  anesthetic  really  are  due  to  the  status  lymph- 
aticus.  Death  may  occur  while  the  patient  is  under  the  anesthetic, 
or,  as  is  more  often  the  case,  a  few  hours  later,  with  symptoms  of 
dyspnea,  rapid,  feeble  pulse,  high  temperature,  and  restlessness,  but 


Fig.  125. — Case  of  severe  knock-knee  due  to  rachitis;  death  from  "status  lymphaticus" 
five  hours  after  double  osteotomy.     Orthopedic  Hospital. 

with  no  evidence  of  traumatic  delirium.  In  the  case  of  the  patient 
shown  in  Fig.  125,  death  occurred  five  hours  after  the  completion 
of  a  double  osteotomy;  and  at  autopsy  no  lesions  could  be  found 
other  than  diflPuse  enlargement  of  the  bronchial  and  mesenteric  lymph 
nodes.  There  was  no  evidence  of  pulmonary  embolism,  fatty  or 
other,  and  death  was  attributed  to  the  status  lymphaticus. 

Heat  Prostration. — Heat  prostration  occasionally  causes  a  post- 
operative death.  The  symptoms  and  treatment  are  the  same  as 
for  heat  prostration  in  other  patients.  It  is  well  to  postpone  all 
operations  but  those  of  immediate  necessity  during  the  prevalence 
of  extremely  hot  weather. 


CHAPTER   VII. 
GUNSHOT  WOUNDS. 

Gunshot  wounds  are  those  produced  by  missiles  projected  by  the 
explosive  action  of  gunpowder.  The  missiles  include  the  various 
projectiles  from  artillery  {shell,  solid-sliot,  cannister,  and  shrapnel); 
hullcfs  from  small-arms  (muskets,  rifles,  revolvers);  as  well  as  small 
shut  from  shotguns.  Solid-shot  and  shells  are  directed  rather  against 
defences  than  the  soldiers  on  guard,  and  these  rarely  are  injured 
except  by  fragments  of  such  large  missiles.  Shrapnel  and  cannister 
are  much  alike,  being  composed  of  a  collection  of  small  missiles 
within  an  iron  casing;  but  cannister  explodes  as  it  is  discharged  from 
the  gun,  while  shrapnel  contains  an  explosive  in  its  centre,  with  a 
time  fuse,  and  is  exploded  only  when  the  time-fuse  is  consumed. 
Both  shrapnel  and  cannister  are  used  only  at  close  range.  The 
injuries  produced  by  all  forms  of  artillery  missiles  are  exceedingly 
destructive,  partaking  of  the  nature  of  contused  and  lacerated  wounds. 
In  naval  warfare  such  wounds  are  much  more  frequent  than  those 
from  small-arms.    Amputation  frequently  is  required. 

Bullet  wounds  comprise  nearly  90  per  cent,  of  those  seen  in  war, 
and  form  almost  the  only  variety  of  gunshot  wounds  encountered 
in  civil  life,  with  the  exception  of  occasional  wounds  from  small-shot 
or  from  wadding  out  of  blank  cartridges.  ^Musket  balls  (round) 
are  no  longer  used  in  civilized  warfare,  their  place  ha^•ing  been  taken 
by  conoidal  bullets  projected  from  rifled  barrels  (Fig.  126).  The 
rifling  imparts  to  the  missiles  a  rotatory  motion,  or  spin,  which  in 
the  case  of  the  modern  ]Mauser  bullet  approximates  2500  revolutions 
per  second  on  its  discharge,  at  which  instant  its  velocity  is  nearly 
2700  feet  per  second  {initial  velocity).  The  ]Mauser  bullet  now  in  use 
in  the  U.  S.  Army  is  0.30-calibre  (/.  e.,  0.30  inch  in  diameter),  and  1.08 
inches  long;  it  consists  of  a  core  of  lead  and  tin  composition  inclosed 
in  a  jacket  of  copper  and  nickel  (Borden,  1913).  The  high  velocity 
imparted  to  the  modern  bullet  tends  to  make  its  trajectory  (line 
of  flight)  more  nearly  horizontal,  thus  increasing  the  danger  zone} 
The  rotary  motion  and  high  velocity,  combined,  tend  to  lessen  the 
bullet's  dip,  thus  enabling  it  to  strike  more  nearly  end-on;  while 
both  factors  markedly  increase  its  penetrating  power.     The  range  of 

iWhen  fired  horizontally  ("point  blank")  the  danger  zone  embraces  the  entire 
trajectory  of  the  buUet,  which  under  such  circumstances  is  about  700  j-ards  in 
length;  when  aimed  at  a  greater  distance  the  shot  is  fired  into  the  air,  the  trajectory 
is  a  paralDohc  curve,  and  the  danger  zone  is  removed  to  the  area  within  which 
the  bullet  is  liable  to  strike  earth. 


cuNsnoT  wni'XDs 


ISl 


thr  modern  niilit;iry  hiillct  is  fairly  accuriitc  up  to  one  mile.  i5ullets 
may  strike  elsewhere  first,  \vouii(liii<i;  the  ])atieiit  only  !)>'  ncoclid, 
after  heiiij;-  deformed  1)\  the  first  iini)a(t;  such  wounds  are  more 
apt  to  he  laceratcil  and  contused. 


Fig.  126.— Evolution  of  the  iMiUct.  1. 
3,  0.4.5-faIibr<-  Springfield;  4,  0.3()-c:ilil)r< 
natural  size.     (Bryant  and  Buck.) 


old  rounded  musket   t 
jacketed  Springfield, 


2,   Minie  Inillet ; 
](■[    190.-,.     .Ml    of 


At  close  range,  the  modern  military  bullet  has  what  is  known  as 
an  explosive  effect;  that  is  to  say,  any  marked  resistance  causes  its 
energy  to  be  transmitted  into  the  surrounding  tissues.  The  more 
resistant  the  tissues,  the  more  marked  is  the  explosive  effect.  This 
is  particularly  noticeable  in  bone:  if  the  spongy,  expanded  epiphyses 
are  struck,  there  is  little  resistance  offered  and  a  grooved  or  tunnelled 
wound  will  })e  produced  (Fig.  127) ;  whereas  if  the  hard  brittle  diaphysis 
is  struck  the  bone  will  be  shattered  (Fig.  128).  Fluid-saturated  or  fluid- 
containing  organs  offer  extreme  resistance  to  bullets,  because  of  their 
lack  of  compressibility;  the  brain,  the  liver,  and  the  hollow  viscera  (if 
distended  with  liquid  or  semi-solid  food)  afford  notable  examples  of 
this  explosive  action  at  close  range.  This  destructive  action  is  due  to 
the  missile's  high  initial  velocity.  Larger  missiles  (as  the  old  round 
shot)  with  much  lower  velocity,  even  when  almost  spent,  may  ha\'e 
an  equally  destructive  action.  These  facts  are  conciseh'  expressed 
in  the  physical  formula  M  =  mv;  that  is,  the  momentum  equals  the 
product  of  the  mass  by  the  velocity,  and  if  either  the  mass  (as  in  the 
larger  missiles)  or  the  velocity  (as  in  the  modern  military  bullet) 
be  sufficiently  great,  the  momentum  of  the  projectile,  and  hence  its 
destructive  action,  will  be  correspondingly  great. 

The  bullet  wounds  encountered  in  civil  life  (suicide,  homicide, 
etc.)  as  a  rule  are  not  produced  by  modern  military  bullets,  but  by 
softer,  unjacketed  bullets  (jNIinie  or  Springfield)  of  low  velocity 
(about  700  feet  per  second) ;  the  calibre  varies  from  0.22  to  0.40  or 
0.45,  but  is  usually  large;  and  the  wounds  much  more  resemble  those 
seen  during  the  War  of  the  Rebellion.  As  in  civil  life  the  bullet  is 
softer,  larger,  and  slower,  it  is  more  easily  deflected  and  deformed, 
and  almost  invariably  lodges  in  the  patient's  body;  the  wound  is  less 
clean  cut,  more  lacerated  and  contused,  than  that  produced  by  the 


182 


GUNSHOT  WOUNDS 


military  bullet;  the  bullet  remains  as  a 
foreign  body;  and  infection  is  much  more 
frequent.    In  war  it  is  very  exceptional 
for  the   bullet  to  lodge  in  the  patient's 
body;  and  owing  to  the  greater  velocity, 
the   direct  impact,    and   the   rectilinear 
course  of  the  bullet  through  the  body, 
and   its   subsequent   absence  from   the 
wound,   infection   is  less  usual.     Unless 
a  large  bloodvessel  or  important  organ 
IS  wounded,  death  in  war  is  seldom  im- 
mediate; but  it  appears  to  occur  in  a 
larger  proportion  of  cases  since  the  intro- 
duction  of    the  modern   bullet,    largely 
because  of  its  penetrating  power,  which 
causes  it  to  cut  cleanly  through  or   to 
groove    large    bloodvessels,    instead    of 
rupturing  or  contusing  them.     The  latter 
result,  commoner   with  the   soft  bullet, 
favored   clotting   and    prevented    death 
from  hemorrhage  on  the  field. 

General  Characterof  Gunshot  Wounds. 
—As  already  noted,  the  wounds  produced 
by  artillery  missiles  are  very  severe,  a 
limb  being  completely  carried  awav,  the 
head  being  blown  off,  or  a  large  portion 


Fig.  127.— Cancellous  bone  perforated  by  bullet 
(After  Helferich.) 


Fig.  128. — Compact  bone  shat- 
tered by  bullet.  (After  Hel- 
ferich.) 


Bi'LiJ'JT  woi'xns 


1S3 


of  tlu'  trunk  \m\v^  actiiiilly  destroyed.  In  cixil  life  such  injuries  are 
oeeasionally  eneouiiterred  in  Mastini;  accidents,  e.\i)losions,  etc.;  tlie 
wounds  are  severely  lacerale(l  and  contused,  and  recjuire  tiie  usual 
treatment  for  sucli  lesions.  As  the  skin  is  elastic,  a  slowly  n)o\injf 
cannon-i»all  t're((nently  lias  j)ro(luced  suhcutaneous  injuries  (fractures, 
rupture  of  xcssels,  etc.),  without  laceratinjj;  the  intef^uuient;  such 
injuries  were  formerly  attril)uted  to  the  "wind"  of  the  hall. 

Bullet  womtdf  are  in  the  nature  of  jjunctured  wounds,  and  either 
pcncfnifr  or  perforate  the  body.  If  they  merely  penetrate,  there  is  only 
a  wound  oj  entruuce;^  if  they  perforate  there  is 
a  wound  of  entrance  and  also  one  of  exit  (Fig. 
120),  except  in  very  rare  cases  where  the 
bullet  makes  a  circuit  within  the  body  and 
emerjfes  again  by  the  wound  of  entrance.  If 
fired  at  close  range  (usually  not  over  3  feet) 
there  will  be  powder-marks  around  the  wound 
of  entrance.  The  wound  of  exit  is  usually, 
esi)ecially  in  civil  life,  larger  than  the  wound 
of  entrance,  and  its  margins  may  be  some- 
what everted.  This  is  due  to  the  bullet  being 
deformed  after  striking,  to  the  reduction  in  its 
velocity,  to  its  carrying  particles  of  flesh  or 
bone  before  it  into  and  out  of  the  wound,  or 
to  it  emerging  sideways  (no longer  "end-on"). 
The  wound  of  entrance  sometimes  seems 
smaller  than  the  missile  by  which  it  was  pro- 
duced, from  the  elasticity  of  the  skin.  If  two 
bullets  enter  b>'  the  same  wound,  one  may  pass 
through  and  the  other  lodge;  or  they  may 
emerge  by  the  same  or  by  difi'erent  wounds; 
and  two  bullets  may  enter  by  different 
wounds  and  emerge  by  the  same  wound  of 
exit.  One  bullet  may  traverse  successively 
various  parts  of  the  body,  making  wounds  of 
entrance  and  exit  in  both  lower  or  upper 
limbs,  or  in  a  limb  and  the  trunk,  or  if  the 
limb  is  acutely  flexed,  traversing  the  same 
limb  twice.  The  track  of  the  bullet  forms  a 
sinus  which  heals  by  the  ordinary  processes 

of  repair.  The  smaller  the  calibre  of  the  bullet,  the  less  likely  is 
sloughing  to  occur;  wounds  by  bullets  of  0.22  calibre  frequently  heal 
without  infection,  even  in  civil  life;  those  by  bullets  of  0.35  calibre  or 
over  almost  invariably  suppurate  throughout  their  extent. 

Symptoms. — These  are  general  and  local.  Shock  is  seldom  marked 
in  modern  warfare,  unless  a  vital  organ  is  wounded,  or  unless  the 
bullet  has  been  fired  at  close  range,  w^ith  explosive  effect;  in  the  heat 

1  This  may  be  within  the  mouth,  or  even  within  the  anus  or  the  external  auditory 
meatus,  when  it  is  readily  overlooked. 


Fig.  129. —  0.3S-calibre 
bullet  wound  in  right  calf. 
Wound  of  entrance  on 
outer  side:  wound  of  exit 
on  median  side.  Five  days 
after  injury.  Episcopal 
Hospital. 


184  GUNSHOT  WOUNDS 

of  battle,  a  soldier  may  be  scarcely  aware  that  he  is  wounded  until 
he  feels  the  trickling  blood.  Traumatic  delirium  occasionally  is 
marked,  sometimes  occurrinji;  at  once,  without  any  ii])])arent  shock. 
Pain  rarely  is  great,  usually  being  merely  a  stinging  sensation,  as 
if  from  a  smart  blow  with  a  whip  or  stick.  Ilemurrhage  seldom  is 
profuse,  unless  from  the  wound  of  a  large  bloodvessel;  under  such 
circumstances  it  is  likely  that  a  large  hematoma  will  form.  Secondary 
hemorrhage  (p.  177)  is  liable  to  occur  at  any  time  until  all  sloughs 
separate. 

Prognosis. — In  warfare  there  is  one  soldier  killed  for  every  four, 
five,  or  six  wounded ;  and  this  proportion  has  been  very  little  altered 
by  the  changes  in  military  equipment.  A  large  proportion  of  gunshot 
wounds,  therefore,  seems  to  be  necessarily  fatal;  but  in  the  remaining 
cases  the  prognosis  depends  almost  entirely  upon  the  treatment. 
By  modern  methods  the  death  rate  has  been  reduced  to  5  or  10  per 
cent.  The  bullet  wounds  of  war  are  not  seriously  infected  of  them- 
selves, and  if  kept  clean  the  resistance  of  the  patients  usually  is 
sufficient  to  ensure  a  good  result,  at  least  as  regards  life.  Injuries 
of  the  trunk  are  more  serious  than  those  of  the  extremities,  because 
of  damage  to  viscera;  but  they  are  also  less  frequent.  Injuries  to  the 
extremities  involving  bones,  joints,  or  bloodvessles  are  more  serious 
than  mere  flesh  wounds.  The  positions  of  the  wounds  of  entrance  and 
exit  frequently  will  enable  the  surgeon  to  exclude  injury  of  important 
structures. 

Treatment. — In  modern  warfare  the  bullet  seldom  lodges,  and 
even  if  it  does,  it  rarely  causes  immediate  trouble;  hence  it  is  not 
necessary  to  remove  it.  Every  soldier  is  supplied  with  a  "first-aid 
packet,"  and  is  instructed  to  apply  the  sterile  gauze  dressing  so  as 
to  occlude  the  wounds  of  entrance  and  exit,  fixing  it  in  place  with 
the  bandage  which  is  attached.  Only  in  case  of  active  hemorrhage 
is  any  operative  treatment  required  on  the  battlefield;  and  if  the 
he;norrhage,  profuse  at  first,  has  ceased  spontaneously,  it  usually  is 
safer  to  apply  a  provisional  tourniquet  (Fig.  Ml)  and  transport  the 
patient,  who  w\\\  be  much  shocked,  to  the  field-hospital  (at  least 
three  miles  from  the  front),  than  to  undertake  what  may  be  a  serious 
operation  in  unfavorable  surroundings.  Here,  or  preferably  at  the 
military  hospital  at  the  nearest  base,  the  injuries  to  nerves,  tendons, 
bones,  etc.,  should  receive  suitable  treatment. 

In  civil  life  the  bullet  generally  lodges,  or  is  arrested  by  the  skin 
on  the  opposite- side  of  the  body;  and  from  its  large  calibre  and  the 
nature  of  the  wound  it  makes,  frequently  requires  removal;  and  this 
is  best  accomplished  within  twenty-four  hours  or  not  until  the  inflam- 
mation has  subsided.  A  bullet  is  best  detected  by  the  .r-rays;  it 
may  be  accurately  located  by  two  exposures  made  at  right  angles  to 
each  other,  with  some  suitable  landmark  as  a  guide  (Figs.  130  and  131). 
If  the  .T-rays  are  not  available,  the  track  of  the  bullet  may  be  probed 
(except  in  wounds  of  the  abdomen),  after  thorough  antiseptic  prepara- 
tion.   A  porcelain-tipped  probe  (Fig.  132),  first  employed  by  Xelaton 


SMALL  SHOT   WOl'XDS 


185 


ii)  the  casi"  of  tlic  (clcltnitfil  (umutuI  Garibaldi  (18()2),  will  retain  the 
marks  ot"  a  soft  lead  hiillet,  e\eii  after  the  hlood  has  heeii  rinsed  ofV 
ill  water;  hut  it  is  of  little  \ise  in  detecting-  the  modern  hard  jacketed 
bullets.  The  stem  of  a  elay  i)ii)C  was  used  by  IIei<i;hway  during'  the 
Mexican  War  (184S).  Tactile  sensation,  transmitted  through  an  ordin- 
ary probe,  may  enable  the  surgeon  to  detect  the  bullet's  presence.    The 


Fig.  130. — Bullet  lodged  in  knee-joint, 
localized  by  skiagraphy;  compare  Figs. 
1.31,  134,  135.     Episcopal  Hospital. 


Fig.  131. — Lateral  view  (skiagraph) 
of  bullet  lodged  in  knee-joint.  Epis- 
copal Hospital. 


bullet  may  be  removed  by  bullet-forceps  (Fig.  132)  introduced  through 
the  nearest  aperture,  or  by  a  counter-incision.  If  the  bullet  is  situated 
at  all  deeply,  in  the  flesh\'  part  of  a  limb,  it  usually  is  necessary  to 
dissect  down  upon  it;  under  such  circumstances  the  finger  is  the  best 
probe.  The  incision  should  be  closed  with  buried  and  superficial 
sutures,  and  drainage  should  be  provided  for  at  least  twenty-four 
hours. 


Fig.  132. — 1,  Nelaton's  porcelain  tipped  probe;  2,  bullet-forceps. 


Small-shot  Wounds. — If  fired  at  close  range,  small-shot  produces 
great  damage,  the  wounds  resembling  those  caused  by  artillery 
projectiles.  I  have  seen  all  the  soft  tissues  on  the  front  of  the  lower 
forearm  carried  away  in  bulk,  necessitating  amputation,  even  though 
the  bones  were  not  fractured.  Fingers,  toes,  and  parts  of  the  hand 
or  foot  are  frequently  blown  off.  If  at  longer  range,  the  shot  scatters, 
there  is  no  powder-burn,  and  comparatively  little  damage  may  be 


186 


GUNSHOT  WOUNDS 


done,  particularly  in  the  case  of  birdsliot.  Of  course  if  the  eye  be 
struck,  or  an  important  nerve  or  bloodvessel  injured,  the  consec|uences 
may  be  very  serious  even  from  the  impact  of  one  or  two  shot.  It  is  a 
tedious  job  to  extract  all  these  small  shot,  and  it  is  seldom  necessary 
to  do  so.  If  the  part  be  treated  as  for  a  contused  wound  it  usually 
does  well. 

Wounds  from  blank  cartridges  scarcely  require  separate  mention. 
They  occur  in  this  country  chiefly  about  the  Fourth  of  July.  I  have 
not  been-  able  to  convince  myself  that  they  are  more  liable  to  be 
followed  by  the  development  of  tetanus,  if  properly  treated,  than 
other  punctured  and  contused  wounds.  If  the  wadding  has  lodged, 
it  should  be  extracted,  entirely  devitalized  tissue  should  be  cut  away, 
the  raw  surfaces  swabbed  with  solution  of  iodin  (3  per  cent.),  and  the 
wound  dressed  antiseptically. 


GUNSHOT   WOUNDS   OF   SPECIAL   STRUCTURES    AND   REGIONS. 

Bloodvessels. — For  primary  hemorrhage,  the  same  rules  apply  here 
as  elsew'here  (p.  230).  Usually  the  bloodvessels  are  more  or  less 
contused  by  bullet  Avounds  in  civil  life,  and  thrombosis  is  sufficient 
to  prevent  free  bleeding;  if  a  bloodvessel  is  struck  by  a  military 
bullet,  howcA'cr,  it  is  cut  across  or  grooved,  and  hemorrhage  is  profuse. 
Secondary  hemorrhage  is  not  unusual,  especially  if  the  wound  becomes 
infected;  its  treatment  is  described  at  p.  232.  False  aneurysm  (p.  233), 
or  arterio-venous  aneurysms  (p.  235)  are  sometimes  remote  conse- 
quences of  gunshot  wounds  of  arteries  and  veins. 

Nerves,  Tendons. — In  warfare  these  are 
not  deflected  by  the  bullet,  but  are  cut 
through.  Nerves  may  be  seriously  injured 
also  by  being  grazed  by  a  bullet,  causing 
what  the  Germans  call  an  "  Frsschhiitter- 
ung"  of  the  nerve  which  England's  great 
lexicographer  might  have  translated  by  the 
term  "tremef action."  Severed  nerves  and 
tendons  should  be  sutured  as  soon  as  proper 
operative  technique  can  be  secured. 

Bones. — Gunshot  fractures  require  the 
same  treatment  as  other  compound  frac- 
tures (p.  312).  The  shafts  are  usually  much 
splintered  (Fig.  128),  unless  injured  by  a 
nearly  spent  bullet,  which  is  then  deformed 
on  striking  (Fig.  133);  fractures  of  the 
epiphyses  are  less  serious,  unless  the  joint 
is  wounded. 

Joints.^Gunshot  wounds  of  joints  were  formerly  exceedingly 
fatal;  in  the  Rebellion  the  mortality  varied  from  9  per  cent.,  for  the 
elbow,  to  84  per  cent,  for  the  hip.  In  the  Turko-Russian  War  (1877) 
von  Bergmann  found  that  death  occurred  in  95  per  cent,  of  gunshot 


Fig.  133.— Soft  bullet  de- 
formed (mushroomed)  by  strik- 
ing bone  end-on.  From  a 
patient  in  the  Episcopal  Hos- 
pital. 


GUNSHOT  worNns  of  special  structures  and  recions   187 

wounds  of  tlie  kiioc-joint  treated  hy  accepted  methods;  lie  tlicrefore 
"selectetl  fifteen  of  the  most  serious  cases  of  gunshot  wound  of  tiie 
knee,  .  .  .  Jind  trciitcd  thi'm  by  immohih'/ation  iind  occhisive 
dressin<;s.  In  these  casi-s,  recoxcry  with  mo\;d)h>  joints  resnhed  with 
hut  a  singh'  ex(('])tion,  where  am])utation  liad  to  he  <h)ne  and  (k-ath 
followed"  (Borden,  1907).  Since  that  time  modern  military  surj^cons 
have  followed  von  Berjjmann's  example,  treating  all  joint  injuries, 
except  those  re^iuiring  inunediate  amputation,  by  aseptic  occlusion 
anil  innnobilization.  In  the  Spanish-American  ^Var,  there  were  forty- 
three  cases  of  injury  to  the  larger  joints,  and  in  only  two  was  operation 
reipiired — amputation  in  both  cases,  with  one  death,  a  total  mortality 
of  2.0  per  cent.;  in  the  Chinese-Japanese  War  there  were  fort\-seven 
injuries,  with  five  deaths,  a  mortality  of  10.0  per  cent. 


Fig.  134. — Result   of  artlirotoniy  and  Fig.   1.35. — Result    of    arthrotoniy    and 

extraction    of    bullet     from     knee-joint;         extraction  of  bullet  from  knee-joint.  Same 
recent  accident.     Episcopal  Hospital.  patient  as  Figs.  130,  131,  and  134.     Epis- 

copal Hospital. 


In  warfare  the  bullet  seldom  lodges,  and  even  in  civil  life  it  is  not 
so  apt  to  lodge  in  the  joint  as  in  the  neighboring  bones  or  soft  parts; 
hence  there  is  no  indication  to  open  the  joint  for  its  removal.  Its 
location  can  be  determined  by  skiagraphy,  and  it  may  be  extracted 
at  a  later  date  if  productive  of  symptoms.  Sometimes  a  bullet  has 
ulcerated  into  the  joint  after  lying  perdu  for  many  years  in  the  end 
of  one  of  the  articulating  bones;  under  such  circumstances  it  produces 
the  symptoms  of  a  foreign  body  or  loose  cartilage  in  the  joint.  Quenu 
(1910)  has  collected  twelve  instances  in  which  a  bullet  was  removed 
from  the  knee-joint  (three  immediate,  and  nine  tardy  operations): 
and    I   have  had   under  my  own   care   the    patient    represented  in 


\RR 


GUNSHOT  WOrXDS 


Figs.  i:^().  i;;i.  i:;4,  ]:]d.  In  E.  II.  Ochsner's  patient  (1910)  a  Inillct  was 
successfully  removed  from  the  hip-joint  ten  years  after  the  injury. 

Head. — Gunshot  injuries  of  the  head  are  most  serious  when 
fracturing  the  skull  or  injuring  the  brain.  The  general  mortality 
from  gunshot  fractures  of  the  skull  has  not  been  materially  reduced 
in  modern  wars,  still  being  nearer  60  than  50  per  cent.  At  close  range 
the  explosive  effect  is  present,  and  death  is  instant  (Fig.  136).  Even  at 
long  range  the  penetrating  power  of  the  modern  bullet  renders  injury 
of  the  brain  much  more  frequent  than  formerly;  and  the  bullet  seldom 
lodges.  In  civil  life  these  injuries  frequently  are  the  result  of  suicidal 
attempts,  the  wound  of  entrance  being  within  the  mouth,  in  the  right 
temple,  or  in  the  forehead.     Even  if  the  brain  is  injured  there  may 


Fig.  136. — Skull,  showing  explosive  effect  of  bullet  fired  at  close  range;  a  and  b, 
wounds  of  entrance  and  exit.     (Von  Bergmann.) 

be  no  localizing  symptoms  (p.  583).  The  only  indications  for  operative 
treatment,  which  in  no  case  should  be  attempted  until  complete 
asepsis  is  assured,  are  (1)  to  disinfect  the  wound  of  entrance;  (2)  to 
arrest  hemorrhage;  (3)  to  repair  damage  to  the  cranium;  and  (4)  to 
remove  a  lodged  missile  if  it  is  producing  symptoms.  If  the  wound 
of  entrance  is  small,  not  liable  to  cause  further  trouble  from  infection; 
if  the  fracture  of  the  skull  is  a  mere  puncture,  without  comminution 
or  fissuring;  if  there  are  no  symptoms  of  internal  hemorrhage  or  com- 
pression of  the  brain;  and  if  the  patient  does  not  grow  progressively 
worse,  no  operation  should  be  done.  If  the  wound  of  entrance  is 
lacerated,  contused,  filthy,  and  splintering  of  the  skull  is  evident, 
operation  should  be  undertaken  as  in  any  case  of  fracture  of  the  skull 


GUNSHOT  WOIWDS  OF  SrEOIAL  STRUCTUJiKS  AM)  U/'XIIOXS    ISO 

whctlier  tlierc  are  (■(Tel)ral  syinj)t()ni.s  or  not.  riidi-r  sucli  circum- 
stances I  o])erate(i  (February,  1909)  successfully  on  a  patient  in  the 
Kpiscopal  Hospital,  with  a  suicidal  wound  in  the  middle  of  liis  fore- 
head, renio\in^f  fraj;ments  of  the  hullet  and  of  hone  from  the  superior 
longitudinal  siiuis.  If  undiT  such  circumstances  the  dura  is  found  to 
be  wounded  it  should  l)e  incised,  and  drainage  provided  for;  but  no 
attem])t  should  be  made  to  remove  the  bullet  from  the  substance  of 
the  brain  unless  it  is  causing  sym])toms.  In  cases  where  it  is  belie\"cd 
the  liullet  is  producing  symj)toms  (for  these  ma\'  be  due  to  hemorrliage 
and  extravasation,  not  to  the  bullet),  its  location  should  be  determined 
by  skiagraphy,  and  its  removal  attempted  by  the  nearest  approach: 
sometimes  the  original  track  may  be  followed,  at  other  times  the 
opposite  side  of  the  skull  must  be  opened.  In  following  the  orginal 
track,  a  heavy  probe  with  a  large  bulbous  end  should  be  selected, 
and  the  patient  should  be  so  placed  that  the  probe  will  sink  by  its 
own  weight  verticall\-  into  the  bullet's  track.  Then  by  passing  a 
bullet -forceps  along  the  probe  as  a  guide,  it  may  be  possible  to  extract 
the  bullet. 

Spine. — Gunshot  wounds  of  the  spine  have  increa.sed  in  severity 
in  recent  wars;  the  mortality  in  the  Spanish-American  and  Philippine 
campaigns  was  (iC)  i)er  cent.  (Borden,  1907).  Nearly  every  case  of 
injury  to  the  spine  is  now  a  compound  fracture:  wounds  of  the  arches 
are  comminuted,  but  a  bullet  may  perforate  the  body  of  a  vertebra 
without  much  damage  to  the  bone.  The  cord  is  frequently  cut  in 
two;  even  contusion  of  the  cord,  or  "Erschiitterung,"  may  result  in 
complete  transverse  lesion.  In  civil  life,  the  slowly  moving  bullet 
usually  is  arrested  by  the  spine,  and  fracture  without  injury  of  the 
cord  is  the  rule.  In  military  practice,  immediate  operation  is  not 
indicated.  The  symptoms,  treatment,  etc.,  of  injuries  of  the  spine 
in  civil  life  are  considered  at  p.  599. 

Thorax. — Gunshot  wounds  of  the  thorax  rarely  are  serious  unless 
they  penetrate  and  wound  the  viscera.  Instant  or  rapid  death  fre- 
quently follows  injury  of  the  heart  or  great  vessels;  but  injury  to  the 
lung  at  some  peripheral  i)oint  may  be  productive  of  no  immediately 
serious  symptoms.  P^specially  is  this  so  in  the  case  of  bullets  of  small 
calibre  striking  at  more  than  000  yards.  In  warfare  the  bullet  seldom 
lodges;  in  civil  life  it  nearly  invariably  is  arrested,  frequently  being 
found  beneath  the  skin  on  the  opposite  side  of  the  body.  It  is  impor- 
tant to  look  for  it  carefully  beneath  the  skin,  if  there  is  no  wound  of 
exit,  so  as  to  determine  if  possible  its  course  through  the  thorax.  A 
bullet  may  seem  to  traverse  the  thorax,  and  yet  wound  no  viscus; 
while  a  wound  which  does  not  penetrate  far  may  cause  alarming 
symptoms  from  hemorrhage  from  the  internal  mammary  or  an  inter- 
co.stal  artery. 

Symptoms. — If  the  bullet  has  traversed  the  thorax  above  the  level 
of  the  fifth  rib,  and  there  are  no  signs  of  serious  internal  hemorrhage 
(p.  277),  it  is  probable  that  the  upper  part  of  the  lung  has  been 
wounded  at  its  periphery.      If  the    bullet  is   of   small    calibre,  the 


100  GUNSHOT  WOrXDS 

pulmonary  tissue  expands  and  occludes  the  wounds  of  entrance  and 
exit  in  the  lung,  and  little  hemorrhage  occurs  into  the  pleural  cavity. 
A  larger  bullet  produces  more  of  a  lacerated  wound,  and  the  signs  of 
hemothorax  (sometimes  pneumo-hemothorax )  quickly  develop.  Sub- 
cutaneous emphysema  (p.  72Sj  is  not  infrequent.  In  nearly  every 
case  the  physical  signs  of  a  more  or  less  diffuse  bronchitis  appear; 
bloody  mucus  is  expectorated;  moderate  fever  occurs;  and  the  patient 
passes  through  an  atypical  attack  of  pneumonia.  Dyspnea  rarely 
is  severe,  unless  from  internal  hemorrhage,  or  from  pneumothorax. 
If  the  track  of  the  bullet  passes  below  the  level  of  the  fifth  rib,  it 
may  wound  the  diaphragm,  or  pierce  this  and  entering  the  abdomen 
wound  the  subdiaphragmatic  viscera.  In  a  patient  under  my  care 
at  the  Episcopal  Hospital  (March,  1909j,  the  wound  of  entrance  was 
in  the  sixth  left  interspace  close  to  the  sternum,  and  the  bullet  lodged 
beneath  the  skin  in  the  eleventh  left  interspace  about  three  inches 
from  the  spine.  It  perforated  the  pericardium  in  two  places,  without 
wounding  the  heart;  then  entered  the  diaphragm,  grooving  the 
esophagus;  perforated  the  left  lobe  of  the  liver;  reentered  the  dia- 
phragm, three  inches  back  of  its  first  passage;  passed  through  the 
lower  border  of  the  lung,  cut  the  intercostal  artery  near  its  origin, 
and  lodged  outside  the  pleura,  as  before  stated.  In  spite  of  prompt 
operation,  tlie  patient  died  on  the  third  day,  of  pneumonia. 

Treatment. — Xo  operation  should  be  done  except  with  the  most 
complete  facilities  for  aseptic  technique.  Wounds  above  the  level 
of  the  fifth  rib.  not  wotmding  the  heart  or  the  root  of  the  lung,  seldom 
require  operation.  The  superficial  wounds  should  be  cleansed  and 
occluded  with  sterile  dressings,  and  the  affected  side  of  the  chest 
strapped,  as  for  fractured  ribs  (p.  323).  Dyspnea  is  to  be  controlled 
by  opiates;  stimulation  by  atropin  and  strychnin  may  be  necessary; 
for  persistent  hemoptysis,  calcium  chloride  or  horse  serum  may  be 
employed.  In  any  case  where  the  abdominal  contents  may  have  been 
wounded,  exploratory  laparotomy  is  indicated.  When  dyspnea  is 
extreme,  and  the  pleura  is  filled  with  fluid,  it  is  better  to  open  the 
pleural  cavity  by  an  intercostal  incision  (in  the  seventh  or  eighth 
interspace),  and  evacuate  the  blood.  Mere  exjoosure  of  the  lung  to 
the  air  usually  is  sufficient  to  control  hemorrhage  from  the  bullet 
track;  if  hemorrhage  persists,  the  orifices  in  the  lung  should  be 
sutured,  and  wounds  in  the  thoracic  parietes  tamponed,  if  ligation  is 
impossible.  To  accomplish  these  manoeuvres  it  may  be  necessary  to 
excise  portions  of  one  or  both  ribs  bordering  the  intercostal  incision. 
When  bleeding  is  arrested,  the  wound  should  be  closed,  with  drainage. 
Empyema  is  a  not  infrequent  sequel,  in  cases  treated  with  or  without 
operation. 

Prognosis. — The  mortality  from  penetrating  gunshot  wounds  of  the 
chest  has  fallen  from  60  to  80  per  cent.,  in  the  wars  of  the  RebelHon 
and  the  Crimea,  to  about  20  per  cent,  in  the  Spanish- American  and 
South  African  wars  (O'Reilly,  1908).  Rochard  (1909)  has  reported 
a  series  of  seventy-one  cases  of  gunshot  wounds  of  the  lungs,  in  civil 


GUNSHOT  WOUNDS  OF  SPECIAL  STRUCTURES  AND  REGIONS    191 

life;  in  only  one  was  operation  necessary;  and  Thiery  (1909)  stated 
that  anionjj  fourteen  cases  of  penetrating  bullet  wounds,  and  one  of 
stab  wound  of  the  lung,  eleven  patients  recovered  without  opera- 
tion; while  of  the  four  whose  condition  was  so  grave  as  to  demand 
operation,  two  succumbed. 

Abdomen. — Gunshot  wounds  of  the  abdomen  may  involve  only 
the  parietes,  and  in  a  patient  with  a  very  fat  or  pendulous  abdomen 
the  bullet  may  enter  in  front  and  lodge  in  the  groin  or  flank  without 
penetrating  the  peritoneum.  In  military  surgery  no  operation  should 
be  undertaken  on  the  field  of  battle,  except  for  alarming  hemorrhage. 
Doche  (1909)  has  shown  that  when  penetrating  abdominal  wounds 
are  treated  by  laparotomy  on  the  field,  more  than  95  per  cent,  termi- 
nate fatally;  but  if  no  operation  is  done,  the  mortality  is  only  50  to 
55  per  cent.  If  the  patient  be  carefully  transported  to  the  nearest 
military  hospital  properly  equipped  for  such  work,  he  may  arrive 
there  still  alive,  and  subsequently  develop  a  localized  abscess,  fecal 
fistula,  or  even  intestinal  obstruction,  which  may  be  treated  success- 
fully by  a  late  operation.  Meantime  the  non-operative  treatment  for 
peritonitis  advised  in  Chapter  XXII  should  be  adopted. 

In  civil  life,  where  adequate  facilities  exist,  immediate  exploratory 
laparotomy  should  be  undertaken,  and  wounds  of  the  viscera  repaired. 
No  symptoms  of  intraperitoneal  infection  should  be  waited  for. 
If  operation  is  done  within  the  first  twelve  hours,  nearly  half  the 
patients  should  recover;  after  that  time  only  one  out  of  four  recovers 
(Coley).  Though  the  mortality  in  civil  practice,  even  after  prompt 
operation,  is  thus  seen  to  be  nearly  as  high  as  that  which  follows 
non-operative  treatment  in  military  surgery,  it  must  be  remembered 
that  the  character  of  the  injuries  in  the  former  instances  is  more 
serious,  and  that  practically  all  such  cases  terminate  fatally  if  not 
operated  upon;  while  in  the  case  of  wounds  received  in  battle,  the 
gastro-intestinal  tract  usually  is  empty,  the  wounds  are  smaller, 
clean-cut,  and  less  contused;  and  many  patients  who  die  on  the 
battlefield  are  not  included  in  the  military  statistics. 

The  diagnosis  and  operative  treatment  of  penetrating  wounds  of 
the  abdomen  are  discussed  in  Chapter  XXII. 


CHAPTER  VIII. 


AMPUTATIONS. 


Amputation,  derived  from  the  Latin  word  meaning  to  lop  off, 
to  prune,  etc.,  is  by  surgeons  usually  confined  in  its  ap])lication  to 
the  removal  of  a  limb,  or  part  of  a  limb.  If  the  member  is  removed 
at  a  joint,  the  operation  may  be  termed  an  exarticidation,  or  a  dis- 
articidcdion;  if  through  the  bones,  the  operation  is  an  (tniijidation  in 
coidinudy. 

Conditions  Requiring  Amputation.  —  Among  the  most  frequent 
and  important  are:  (1)  Avuhion,  or  traunudic  amputation,  of  a  limb; 
here  there  is  no  alternative  but  to  trim  up  the  stump  that  is  left  so 
as  to  hasten  healing  and  secure  good  functional 
result.  (2)  Compound  fractures  and  luxations, 
which  sometimes  leave  the  limb  attached  only 
by  a  few  shreds  of  muscle  or  a  strip  of  skin. 
(3)  Lacerated  and  contused  ivounds,  even  without 
fracture,  sometimes  exhi})it  such  extensive 
destruction  of  the  soft  parts  as  to  demand 
the  removal  of  the  limb.  In  general,  if  the 
limb  is  sure  to  be  useless  if  retained,  or  if  it  is 
sure  to  become  gangrenous,  it  should  be  re- 
moved. (4)  r/o/;///Y7/p,  when  constituting  more 
than  a  superficial  slough,  usually  is  a  cause 
for  amputation.  The  special  varieties  of  gan- 
grene, and  the  proper  time  for  amputation,  as 
well  as  the  level  where  this  should  be  done, 
have  been  considered  in  Chapter  II.  (5)  Dis- 
eases of  Bones  and  Joints.  These  are  much 
less  often  a  cause  for  amputation  now  than 
formerly.  (6)  Injury  of  the  main  artery  of  a 
limb,  when  it  occurs  at  a  site  which  habitually 
results  in  gangrene,  usually  is  a  cause  for 
amputation  (p.  62).  (7)  Mcdignant  tumors 
frequently  necessitate  amputation.  (8)  De- 
formity, including  also  certain  non-malignant 
tumors,  may  very  occasionally  be  a  cause  for 
amputation. 
Instruments. — These  include  a  tourniquet  (Fig.  lo7),  or  an  Esmarclis 
hand  (Fig.  138)  for  controlling  the  circulation;  amputating  knives  for 
dividing  the  soft  parts;  periostcotome,  or  raspatory;  retractors  to  guard 
the  soft  parts  from  the  saw;  bone  forceps,  to  steady  the  bone  as  it  is 


Fig.    137. — ^Screw    tourni 
quet  applied  to  thigh. 


INSTIU'MENTS 


193 


sawed,  in  cases  of  axulsioii  or  traimiiitic  amputation,  and  Itoiir  iiipjx'r.i 
to  trim  rouj'li  edj^es  oil'  the  hone  after  it  has  heen  sawed;  luniiostatic 


Fig.  138. — Esniarch  band,  showing  proper  method  of  its  application 


Fig.  1.39. — Amputating  instruments.  1.  Large  amputating  knife.  2.  Catlin  (double- 
edged  knife).  .3.  Small  amputating  knife.  4.  Metacarpal  knife.  5.  Periosteotome  or 
ra.spatorj'.     6.   Phalangeal  .saw.     7.   Metacarpal  saw.     8.   Large  amputating  saw. 

forceps,   as  well  as  ligatures,   sutures,    needles,    and   scissors.     These 
in.struments  are  illustrated  in  Figs.  139  and  140. 
13 


194 


AMPUTATIOXS 


Tourniquet. — The  screw  tourniquet  (Petit,  WM))  is  seldom  employed 
now,  Ksmarch's  elastic  band  (1873)  having  largely  superseded  it. 
Before  applying  either,  especially  in  shocked  or  anemic  patients, 
the  limb  should  be  elevated  for  a  few  moments,  so  as  to  empty  it  of 
venous  blood.  The  tourniquet,  when  used,  should  be  ])laced  upon 
the  limb  so  that  the  screw  is  either  directly  over  the  main  vessels,  or 
at  a  point  diametrically  opposite  to  them,  compressing  them  against 
bone;  and  a  compress  (as  a  roller  bandage)  should  be  placed  between 
the  tourniquet  and  the  main  vessels,  so  that  greater  pressure  will  he 
brought  to  bear  on  them  than  on  the  surrounding  soft  parts.  After 
fixing  the  touniirjuet  in  j^lace  by  buckling  the  strap  tight,  the  plates 


•-^^^*^^si^'?s5S:;^gs;^;sg^i^ 


Fig.  140. — Amputating  instruments.  1.  Hemostatic  foceps.  2.  Curved  hemostatic 
forceps.  3.  Fergusson's  '"lion-jawed"  bone-holding  forceps.  4.  Liston's  bone-cutting 
forceps  ("nippers").    5.  Farabeuf's  bone-holding  forceps. 


are  separated  by  turning  the  screw,  thus  drawing  the  encircling  strap 
tighter  and  forcing  the  compress  against  the  vessels  until  distal 
pulsation  is  arrested.  Esmarch's  elastic  band  is  wrapped  around 
the  limb  three  or  four  times,  each  turn  being  directly  superposed 
upon,  and  being  drawn  a  little  tighter  than  the  previous  one,  until 
the  circulation  is  arrested.  If  not  drawn  tight  enough,  it  will  increase 
venous  bleeding;  if  drawn  too  tight,  it  may  cause  local  sloughing 
and  subsequent  gangrene  of  the  entire  limb;  or  paralysis  from  pres.sure 
on  the  nerves,  especially  above  the  elbow,  when  the  ulnar  or  musculo- 
spiral  nerve  may  be  injured.  In  emergencies  the  "Spanish  windlass" 
(Morel,  1G74)  may  be  used  (Fig.  1-il),  or  even  Momburg's  method  of 
hemostasis  (p.  21(3). 


OPERA  TI  VE  I' ROC  ED  URES 


195 


Amputating  Knives.  'Vhv  Iciij^'tli  should  he  jilxHit  one  and  a  half 
times  the  tlianieter  of  the  linih  to  be  removed,  and  the  blade  should 
be  from  f  to  f  of  an  inch  wide;  one  of  e'ifr,ht  or  ten  inches  is  suitable 
for  the  thi<;h  or  hip;  one  of  six  for  the  forearm,  arm,  or  lejij;  while 
for  the  hand  or  foot  a  metaearj)al  amputatin<^  knife  (Fig.  1-^9,  4), 
with  a  blade  three  inches  long  and  |  inch  wide,  is  preferable. 
Double  edged  catlins  occasionally  are  used  for  the  forearm  or  leg, 
to  aid  in  clearing  the  interosseous  space.  The  rasjmtory  is  used  to 
scra])e  up  the  })eriosteum  before  applying  the  saw,  thus  leaving  a 
curt"  i)f  periosteum  to  cover  the  end  of  the  bone.  The  retractor  is 
made  of  muslin,  being  two-tailed  for  the  humerus  and  femur  (Fig. 
142),  and  three-tailed  for  the  forearm  and  leg  (P'ig.  143). 


Fig.  142. — Two-tailed  muslin  retractor,  for  amputations 
of  the  arm  and  thigh. 


Fig.  141.— The  "Spanish 
windlass." 


Fig.  143. — Three-tailed  retractor  applied  for  an 
amputation  of  the  leg. 


The  amjyutativg  saw  is  about  ten  inches  long  by  two  and  a  half 
wide;  strong-backed,  and  with  widely  set  teeth.  A  smaller  saw 
is  used  for  the  hand  and  foot.  Bone-ni'ppers  are  sometimes  used 
for  amputating  phalanges,  though  they  are  apt  to  splinter  the 
bone;  and  if  larger  bones  are  properly  sawed,  there  should  be  no 
rough  edges  to  trim  off.  Ligatures  are  of  absorbable  material,  as 
are  the  buried  sutures;  skin  sutures  usually  are  of  silkworm  gut. 

Operative  Procedures. — A  patient  who  is  to  have  a  limb  removed 
usually  is  in  a  weakened  and  precarious  state,  either  from  shock 
and  hemorrhage  following  an  accident,  or  from  the  cachexia  of  chronic 
disease.     Hence  it  is  the  surgeon's  duty  to  take  special  pains  to 


196  AMPUTATIONS 

prevent  loss  of  bodily  heat,  and  needless  waste  of  time.  In  cases 
of  accident  it  frequently  is  necessary  to  prepare  the  limb  for  ampu- 
tation after  the  patient  is  on  the  table,  while  the  anesthetic  is  being 
administered.  The  surgeon  and  his  first  assistant  should  be  ready 
to  commence  the  operation  the  instant  that  the  patient  is  under  the 
anesthetic,  and  the  preparation  of  the  limb  should  be  complete  at 
the  same  time.  While  one  assistant  raises  the  limb,  the  surgeon 
applies  the  tourniquet,  or  if  he  entrusts  this  important  duty  to  an 
assistant,  he  should  make  sure  before  commencing  his  operation  that 
the  circulation  is  properly  arrested  and  that  there  is  no  danger  of 
the  tourniquet  slipping.  One  assistant  should  give  his  entire  attention 
to  the  tourniquet  throughout  the  operation.  Another  assistant  holds 
the  limb  in  a  convenient  position,  clear  of  the  table,  and  the  surgeon, 
standing  with  his  left  hand  to  the  patient's  trunk, ^  divides  the  soft 
parts,  as  will  be  presently  directed;  then  raises  the  periosteum  for 
about  an  inch;  and,  while  the  soft  parts  are  drawn  out  of  the  way  and 
protected  by  the  retractor,  saws  the  bone,  his  assistant  guarding 
against  binding  of  the  saw  by  the  manner  in  which  he  holds  the 
limb.  As  soon  as  the  limb  has  been  removed,  the  surgeon  applies 
to  the  face  of  the  stump  a  folded  towel,  lightly  wrung  out  of  very 
hot  corrosive  sublimate  solution;  this  checks  the  slight  venous  ooze, 
and  as  it  is  gradually  withdrawn,  the  surgeon  catches  with  hemostats 
all  the  vessels  large  enough  to  have  names,  and  ties  them  all.  The 
main  artery  and  vein  of  the  arm  or  thigh  should  be  tied  separately; 
smaller  arteries  may  be  included  in  one  ligature  with  their  accom- 
panying veins.  Then  another  hot  antiseptic  towel  is  applied  to  the 
face  of  the  stump,  and,  the  limb  being  held  as  nearly  vertical  as 
possible,  the  tourniquet  is  completely  removed.  If  it  is  only  partially 
loosened,  venous  bleeding  is  increased.  If  the  surgeon  has  done  the 
operation  with  due  care  there  should  now  remain  only  a  few  oozing 
points  in  the  muscular  masses,  which  can  be  controlled  by  sutures. 
Any  redundant  tendons  or  nerves  are  next  retrenched,  and  the  peri- 
osteum drawn  down  over  the  bone.  Hemorrhage  from  the  medulla, 
w^hich  is  unusual,  should  be  controlled  by  plugging  wdth  muscle  tissue, 
by  packing  with  Horsley's  wax,  or  in  emergency  with  gauze.  Finally, 
the  stump  is  closed,  with  a  few  buried  mattress  sutures  of  chromic 
catgut  approximating  the  ends  of  opposing  sets  of  muscles.  A  rubber 
drainage  tube  is  placed  across  the  face  of  the  stump,  just  beneath  the 
skin,  and  the  skin  is  closed  with  interrupted  sutures  of  silkworm  gut. 
Dressing  the  Stump. — ^Moderate  pressure,  rest,  and  mechanical 
protection  are  necessary.  Abundant  sterile  gauze  dressings  are 
applied,  and  in  a  certain  definite  manner.  Ruffled  gauze  is  placed 
around  each  end  of  the  tube,  one  end  of  which  may  be  left  long  and 
brought  out  of  the  deep  into  the  superficial  dressings,  as  described 
at  p.  160.  The  special  amputation  dressing  is  cut  as  shown  in  Fig. 
144;   the  horizontal   portion   is  placed  beneath  the  limb,  and  folded 

'  In  amputating  the  left  lower  extremity  he  stands  between  the  patient's  legs. 


CIRCLLAli   A  MITT  A  TIOX 


197 


Fig.  144. — Method  of  cutting  and  ap- 
plying gauze  for  dressing  an  amputation 
stump. 


around  it.  the  xcrtical  portion  Ix'iii^^  then  t'oMcd  up  over  the  end  of 
the  stump.  .\  second  siuiilar  dressin<;'  is  apphed  oxer  the  first,  in 
reverse  order,  the  horizontal  ])ortion  hein^^  phiced  dhort'  the  linih, 
and  the  \'ertieal  flap  hein^  drawn 
<h)\vn  over  the  end  of  the  stunij) 
Ix'fore  the  side  pieces  are  fohled 
around  it.  C)\er  tlie  gauze  dress- 
ings an  abunilant  amount  of 
sterih'  absorbent  cotton  is  ar- 
ranged, burying  the  end  of  the 
tul)e,  and  the  whole  is  band- 
aged snugly  on  to  the  stumj). 
It  is  surprising  how  much  dimi- 
nution in  size  an  apparently 
bulky  dressing  undergoes  when  it 
is  properly  bandged.  Next  the 
limb  is  bandaged  firmly  toa  splint, 
which  projects  some  inches  be- 
yond the  end  of  the  stump.  It 
is  never  safe  to  assume  that  cases 

of  amputation,  especially  recent  accidents,  will  be  free  from  traumatic 
delirium,  and  the  proper  time  to  protect  the  limb  from  injury  is  before 
the  delirium  develops.  The  stump  should  be  kept  as  nearly  vertical  as 
possible  for  twelve  hours.  Usually  the  drainage  tube  may  be  removed 
at  the  end  of  twenty-four  to  thirty-six  hours ;  and  the  stump  need  not 
be  dressed,  if  all  goes  well,  until  time  to  remove  the  skin  sutures. 

Methods  of  Operating. — Every  method  of  amputating  may  be 
considered  a  variety  of  either  the  circular  or  the  flap  method.  The 
circular  method  is  to  be  preferred  whenever  a  choice  is  possible; 
it  is  suited  for  all  limbs  where  the  bones  are  approximately  in  the 
centre  of  the  soft  parts  (lower  forearm,  arm,  thigh),  provided  the 
limb  is  not  conical  in  shape.  It  is  not  desirable  in  amputations  at 
joints,  nor  in  the  leg,  where  a  weight-bearing  stump  is  sought,  since 
the  cicatrix  always  falls  across  the  face  of  the  stump. 

Circular  Amputation. — In  this  method  all  the  tissues  of  the  limb 
are  severed  by  circular  incisions,  the  skin  at  the  lowest,  the  muscles 
at  an  intermediate,  and  the  bone  at  the  highest  point  ("triple  in- 
cision" method).  The  surgeon  passes  the  knife  under,  around,  and 
over  the  limb,  so  that  its  point  is  down,  and  its  back  toward  his  own 
face  (Fig.  145);  then,  pressing  the  heel  of  the  knife  well  into  the  flesh, 
with  one  long  steady  sweep  he  divides  the  skin  and  subcutaneous 
tissues  down  to  the  deep  fascia,  the  blade  ending  with  its  point  exactly 
in  the  place  where  its  heel  began  the  incision.  If  the  skin  does  not 
now  retract  sufficiently,  the  surgeon  dissects  it  up,  with  the  same 
knife,  for  a  distance  equal  to  half  the  diameter  of  the  limb,  taking 
care  always  to  direct  his  blade  toward  the  deeper  structures  so  as 
to  leave  uninjured  the  cutaneous  vessels,  and  thus  ensure  the  vitality 
of  the  skin.     Then  the  muscles  are  similarly  divided  down  to  the 


198 


AMPUTATIONS 


Fig.  145. — Circular  amputation  of  the  thigh,  showing  method  of  holding  the 
knife  as  the  first  incision  is  started. 


Fig.  146. — Rkiagraph  of  stump  resulting  from  amputation  of  leg  by  modified 
Sedillot  method. 


FLAP   AMPI'TATIOS  199 

bone,  with  the  same  knife,  by  a  eircular  cut  at  the  point  of  refleetion 
of  the  skin.  The  nuiseles  are  not  separated  from  the  j)eriosteum 
further  than  is  necessary,  but  this  is  cut  througli  by  tlie  periosteotome, 
an<l  serajx'd  upward  for  an  incli  or  more.  In  the  forearm  and  h'g 
the  interosseous  space  nuist  be  ck'ared  also;  in  doing  this  the  surgeon 
shoukl  stu(Hously  avoid  turning  the  edge  of  his  knife  uj)\vard,  toward 
the  patient's  trunk,  for  fear  of  nicking  bloodvessels  higher  than  they 
can  be  conveniently  tied.  When  the  bone  has  been  cleared  fo.r  an 
inch  or  over,  the  muslin  retractor  is  applied,  each  end  overlapping 
the  other,  and  all  being  drawn  upward  by  an  assistant.  The  bone 
is  then  sawed,  at  right  angles  to  its  long  axis.  In  the  forearm  both 
bones  are  sawed  at  the  same  level,  and  simultaneously;  in  the  leg, 
the  fibula  is  sawed  first  and  at  least  half  an  inch  higher  than  the 
tibia  (Fig.  146).  After  suturing  the  muscles,  the  skin  incision  may 
be  closed  transversely  or  antero-posteriorly,  as  seems  best. 

Sometimes  in  a  conical  limb  there  is  difficulty  in  dissecting  back 
the  circular  cuff  of  skin,  as  above  described;  then  it  may  be  slit  at 
one  or  two  points.  If  slit  at  only  one  point,  and  the  angles  rounded 
off,  this  constitutes  the  Oval  or  Elliptical  Method,  which  is  habitually 
used  in  many  amputations,  without  the  formality  of  commencing 
it  as  a  circular  amputation,  by  making  the  first  skin  incision  in  the 
form  of  an  ellipse.  If  the  cuft'  of  skin  is  slit  at  two  points,  and  the 
angles  rounded  off,  the  amputation  becomes  one  by  skin  flaps,  com- 
monly called  the  Modified  Circular  Method. 

Flap  Amputation. — The  flaps  may  include  skin  only,  as  in  the 
modified  circular  method;  the  skin  and  superficial  muscles;  or  the 
entire  muscular  mass  with  the  skin.  The  flaps  may  be  rectangular 
or  curved  in  outline,  and  may  be  cut  from  without  inward  or  by 
transfixion.  They  always  should  be  of  equal  breadth  at  their  base, 
whether  they  are  of  equal  or  unequal  length.  Their  combined  length 
should  equal  one  and  a  half  times  the  diameter  of  the  limb.  Care 
should  be  exercised  to  have  the  main  bloodvessels  in  one  flap  or  the 
other  (usually  in  the  shorter),  and  not  at  a  point  where  they  may  be 
slit  up  as  the  flaps  are  being  formed.  In  amputating  by  transfixion 
the  surgeon  raises  the  tissues  to  be  cut  with  his  left  hand,  and,  entering 
the  point  of  the  knife  at  the  side  of  the  limb  nearest  himself,  pushes 
it  across  and  around  the  bone,  and  brings  its  point  out  diametric- 
ally opposite  its  place  of  entrance.  The  flap  is  then  formed  by 
cutting  first  downward  and  then  rapidly  outward,  with  a  vigorous 
sawing  motion.  The  knife  is  then  reentered  as  before,  passing  on 
the  opposite  side  of  the  bone,  and  the  second  flap  is  cut.  The  remain- 
ing fibres  are  then  divided  by  a  circular  sweep,  and  the  operation 
terminated  as  already  described.  The  flap  which  contains  the  prin- 
cipal bloodvessles  should  be  cut  last.  Frequently  it  is  more  con- 
venient to  form  the  first  flap  by  cutting  from  without  inward,  and  the 
second  flap  only  by  transfixion.  Though  an  amputation  may  be 
performed  more  rapidly  by  transfixion,  this  method  has  lost  in  favor 
since  the  introduction  of  anesthesia;  since  by  cutting  from  without 
inward  the  flaps   may  be  more  accurately  shaped,  and  the  main 


200 


AMPUTATIONS 


bloodvessels  may  be  severed   transversely,   instead   of  obliquely  as 
frequently  hai)pened  in  cutting  flaps  by  transfixion. 

Multiple    Amputations. — It    is    occasionally    necessary   to    remove 
two  or  more  limbs  at  the  same  time.     Under  such  circumstances  it 

is  l)est  to  do  the  amputation  of 
greatest  magnitude  and  severity 
first;  and  for  the  same  surgeon  to 
proceed  immediately  afterward  to 
remove  the  second  and  third  limb, 
if  the  patient's  condition  warrants 
the  continuance  of  the  operation. 
If  it  does  not,  hemorrhage  from 
the  remaining  limb  or  limbs  must 
be  temporarily  controlled,  and 
Further  operation  postponed.  For 
two  or  more  surgeons  to  operate 
on  different  limbs  simultaneously 
usually  increases  the  shock  to  the 
l)atient.  Multiple  amputations  for 
gangrene  following  frostbite  are 
much  less  serious  than  those  for 
traumatic  cases.  Fig.  147  shows  the 
result  of  synchronous  amputation 
of  both  arms  in  a  patient  imder 
the  care  of  Dr.  H.  C.  Deaver,  in 
the  Episcopal  Hospital. 
Structure  and  Diseases  of  Stumps. — A  stump  not  only  goes  through 
the  processes  of  inflanmiatory  reaction,  cicatrization,  and  contraction; 
but  there  also  occurs  actual  atrophy  of  the  muscular  tissues  from 
disuse;  the  bone  becomes  rounded  off  and  atrophies;  the  nerves  degen- 
erate, and  sometimes  become  bulbous  and  painful  from  the  develop- 
ment of  fibromas  upon  their  ends.^  The  muscles  occasionally  become 
unduly  atrophied  and  retracted,  leaving  the  ends  of  the  bone  covered 
only  bj'  skin,  or  even  causing  the  incision  to  break  open,  and  pro- 
ducing a  painful  ulcer.  Sometimes,  from  continued  growth  of  bone,  a 
conical  stump  is  formed  (Fig.  148).  This  usually  is  due  to  the  natural 
development  of  the  bone,  being  seen  oftenest  in  amputations  of  the 
upper  arm  in  children,  as  the  growth  of  the  humerus  takes  place 
chiefly  at  the  upper  epiphysis.  Sometimes  a  conical  stump  forms 
in  the  leg  in  childhood,  the  growth  occurring  from  the  upper  epiphysis 
of  the  tibia;  whereas  in  the  forearm  and  thigh,  the  greater  part  of 
the  growth  comes  from  the  lower  epiphyses.  For  conical  stumps, 
and  for  intractable  ulcers,  adherent  to  the  bone,  which  cannot  be 
cured  by  palliative  means,  there  is  no  remedy  short  of  re-amputation, 
which,  fortunately,  is  a  much  less  serious  operation  than  amputation. 
It  sometimes  is  possible  to  resect  the  end  of  the  bone  subperiosteally, 
without  doing  a  formal  amputation  again. 

1  Mumford  (1910)  sutures  the  ends  of  the  nerves  to  each  other,  to  prevent  the 
development  of  false  neuromas. 


Fiii.  147.  —  Douhlo  amputation 
(crush)  eight  weeks  after  operation. 
(Dr.  H.  C.  Deaver's  case.)  Episcopal 
Hospital. 


DISI'JASKS   OF  ST r MI'S 


201 


A   (/ood  sfiniip  is  one   which   is   paiiik'ss  and    which,  in   tlic   lower 
extremity,  can  he  nsed  to  snjjport   the  weight  of  the  body  tiirougii 


Fig.  148. — Conical  or  sugar-loaf  stump  from  continued  growth  of  bone  after  ampu- 
tation in  early  youth.  From  a  patient  in  the  Pennsylvania  Hospital  under  the  care 
of  the  late  Prof.  Ashhurst. 


an  artificial  Hmb.  The  bones  sliould  be  well  covered  w^ith  soft  parts, 
and  these  soft  parts  should  not  be  adherent  to  the  ends  of  the  bone;  if 
there  are  no  such  adhesions  it  makes  no  particular  difference  whether 

the  cutaneous  cicatrix  lies  across  the 
end  of  the  stump  or  at  one  side; 
but  there  are  much  less  apt  to  be 
adhesions  to  the  bone  if  the  cicatrix 
of  skin  as  well  as  of  muscle  lies  to 
one  side  of  rather  than  directly  over 
the  end  of  the  bone.  Few  stumps 
will  bear,  by  direct  pressure  on  their 
ends,  the  entire  weight  of  the  body, 
and  most  artificial  limbs  are  made 
to  obtain  their  chief  support  from 


Fig.  149.  —  Bier's  osteoplastic 
method  of  amputation.  The  bones 
are  sjjwed  at  two  levels,  and  a  flap 
of  the  tibia  turned  acrcjss  the  ends 
at  the  last  section. 


Fig.  150. — Amputation  of  leg  by  aperiosteal 
method  of  Bunge. 


202 


AMPUTATIONS 


surrounding  bony  points  (head  of  the  tibia,  tuberosity  of  the  ischium). 
But  Bier  (1895)  has  advocated  an  osteoplastic  raethofl  of  amputating, 
after  the  Pirogoff  principle,  by  means  of  which  end-bearing  stumps 
may  be  obtained  (Fig.  149).  Bunge  (1905)  has  found  that  by  sawing 
the  bone  2  mm.  below  the  level  at  which  the  periosteum  is  dixided, 
and  scraping  out  the  marrow  cavity  for  the  same  distance,  end-bearing 
stumps  may  be  obtained  without 
any  osteoplastic  operation.  He 
makes  his  flaps  of  skin  only  (Fig. 
150).  The  oval  method  is  suitable 
for  such  cases.  I  have  used  this 
method  with  perfect  success  (1911) 
(Fig.  151). 


Fig.  151. — End-ljoarinK  .stump  (apori- 
osteal  method  of  Buiigej.  Patient  bearing 
all  his  weight  on  the  stump  twenty-five 
days  after  amputation.  Episcopal  Hospital. 


Fk;.  I.jL'. — .Ain|Hii.iti'iii  for  eineniatic 
prosthesis;  freely  iiiovahlc  stump  secured 
by  a  loop  composed  of  biceps  and  triceps. 
Episcopal  Hospital. 


Cinematoplastic  Amputations. — Vanghetti  (1906)  and  other  surgeons 
have  devised  and  practised  methods  of  amputating  the  upper  extremity 
which  provide  for  voluntary  motion  in  the  prosthesis.  In  cases  of 
recent  accidents,  the  limb  is  amputated  in  the  ordinary  manner,  and 
when  the  patient  has  recovered  his  normal  health,  the  stump  is  re- 
opened, and  the  flexor  and  extensor  muscles  are  sutured  to  each  other 
in  the  form  of  a  loop,  over  the  end  of  the  bone,  which  is  resected  if 
too  long;  the  loop  so  formed  is  covered  on  all  sides  by  flaps  of  skin. 
When  healing  is  complete  a  stout  cord  is  passed  through  this  tendinous 
loop,  and  each  end  of  the  cord  is  attached  to  the  mechanism  of  the 
prosthesis.  The  patient  can  then,  by  drawing  on  the  flexor  or  extensor 
side  of  his  tendinous  loop,  flex  or  extend  the  artificial  hand.  I  have 
adopted  this  method  in  some  cases,  but  so  far  have  not  found  any 


MORTALITY   AFTER   AMI'CTATIOX 


203 


manufjK'turor  in  this  country  who  will  furnish  the  desired  cinematic 
prosthesis  (Fi|;.  152j.  Another  method,  practised  hy  Francesco  (1908), 
is  to  detach  tlie  end  of  bone  from  its  diaj^hysis,  still  leaving  it  buried 
in  the  muscular  mass  at  the  end  of  the  stump.  When  healing  is 
comi)lete,  a  ring  of  iron  is  applied  around  the  stump  l>etwecn  the 
knob  of  bone  antl  the  diaphysis  frf)m  which  it  has  been  detached.  As 
the  detached  knob  of  bone  is  voluntarily  movable,  the  ring  above  it 
can  be  inclined  in  any  direction,  and  through  attached  cords  transmits 
the  movements  to  the  prosthesis. 

Mortality  after  Amputation. — Although  this  depends  much  more  on 
the  condition  of  the  patient  than  on  any  other  single  factor,  it  is 
nevertheless  proper  for  the  surgeon  to  be  familiar  with  the  relative 
mortality  of  amputations  for  injury  and  for  disease;  and,  in  cases 
of  injury,  with  that  which  accompanies  primary,  intermediate,  and 
secondary  operation;  as  well  as  the  average  mortality  which  attends 
amputation  in  different  regions  of  the  body.  Primary  amputations 
are  those  done  before  the  inflammatory  process  has  had  time  to 
develop — generally  speaking,  those  done  within  twelve  hours  of 
injury;  intermediate  amputations  are  those  done  during  the  height  of 
the  inflammatory  process;  and  secondary  amputaiions  are  those 
performed  after  its  subsidence,  when  the  operation  resembles  that 
done  for  disease.  As  a  rule,  the  lowest  mortality  attends  primary' 
amputations;  and  though  since  the  introduction  of  antiseptic  methods 
there  is  less  inflammatory  reaction  than  formerly,  nevertheless 
intermediary  amputations  still  give  the  highest  mortality.  In  the 
case  of  secondary  amputation  the  results  are  not  so  good  as  they 
seem,  many  patients  being  too  shocked  for  primary  amputation, 
and  dying  before  secondary  amputation  can  be  attempted.  The  fol- 
lowing table  shows  the  death  rate  attending  amputations  in  various 
portions  of  the  body,  for  injury  and  for  disease,  as  observed  at  the 
Episcopal  Hospital,  Philadelphia,  1900  to  1913  inclusive: 


Amputations  at  the  Episcopal  Hospital,  Philadelphia,  190C 

1-1913 

Inclusi\t;. 

For  injury. 

For  disease. 

Recov- 

Mortality, 

Recov- 

Mortality, 

Region. 

No. 

ered. 

Died. 
0 

per  cent. 

No. 
1 

ered. 
1 

Died. 

per  cent. 

Hand        .      .      . 

17 

17 

0 

Wrist-joint 

1 

1 

0 

■  • 

Forearm  . 

10 

10 

0 

ii 

3 

6 

Arm    .... 

30 

29 

1 

3.3 

3 

2 

1 

33.3 

Shoulder  . 

8 

8 

0 

4 

3 

1 

25.0 

Interscapulo- 

thoracic 

1 

0 

1 

100.0 

Foot    ... 

18 

17 

1 

5.0 

3 

2 

1 

.33.3 

Leg     .... 

54 

49 

5 

9.2 

16 

S 

8 

50.0 

Knee  or  knee-joint 

6 

6 

0 

3 

1 

2 

66.0 

Thigh       .      .      . 

27 

25 

2 

7.4 

18 

10 

8 

44.4 

Hip     ...      . 

3 
175 

1 

2 
^12 

66.6 
6.9 

1 
52 

1 

31 

0 

... 

Total    ,      .      . 

163 

21 

40.3 

204  AMPUTATIONS 

It  has  usually  been  taught,  and  it  is  still  stated  by  many  surgeons, 
that  amputations  for  disease  are  attended  by  a  much  lower  death 
rate  than  those  for  injury.  While  this  was  perfectly  true  before  the 
general  adoption  of  antise])tic  methods  and  modern  methods  of 
treating  shock  and  hemorrhage,  I  tiiink  the  relati(jn  is  now  reversed, 
though  the  extremely  high  mortality  shown  for  amputations  for 
flisease  in  the  above  table  is  to  be  explained  by  the  fact  that  a  large 
majority  of  the  patients  were  suffering  not  from  tuberculous  arthritis 
or  malignant  tumors,  l)ut  from  diabetic  or  senile  gangrene.  Yet 
the  mortality  in  amputations  for  disease  in  this  series  is  scarcely 
higher  than  that  which  attended  amputations  for  injury  before  the 
antiseptic  period. 

Treatment  of  Crushed  Limbs. — The  first  thing  to  do  is  to  control 
hemorrhage  and  combat  shock.  The  limb  should  be  held  vertically, 
and  an  Esmarch  band  applied  as  near  to  the  crushed  area  as  practicable; 
the  foot  of  the  bed  should  be  raised,  and  in  cases  of  grave  anemia  the 
other  extremities  should  be  bandaged  from  the  periphery  toward 
the  trunk  (auto-transfusion) .  The  application  of  external  heat,  and 
other  methods  detailed  at  p.  175,  should  be  employed  for  shock. 
If  any  vessels  can  be  recognized  in  the  wound  they  should  be  ligated ; 
and  any  projecting  nerves  should  be  injected  with  a  sterilized  eucain 
solution  (2  per  cent.),  since  by  nerve  blocking  it  is  possible  to  check 
the  peripheral  impulses  which  cause  shock.  Amputation  should  be 
done  as  soon  as  the  yatient  reacts,  or  at  once  if  the  shock  is  not  marked. 
//  reaction  once  occurs  no  delay  in  amjmtating  should  he  allowed,  as 
the  improvement  frequently  is  only  fleeting,  unless  the  mangled 
limb  is  removed.  The  Esmarch  band  should  not  be  left  in  one  place 
more  than  four  or  five  hours;  sometimes,  on  removing  it,  no  further 
bleeding  will  occur;  but  usually  a  little  ooze  persists,  and  the  band 
should  be  re-applied  higher  on  the  limb.  In  a  few  hours  its  position 
should  again  be  shifted  (applying  a  second  before  removing  the  first, 
if  necessary),  since  in  this  way  it  is  possible  to  keep  the  bleeding 
checked  without  endangering  the  vitality  of  the  parts  above  the 
wound. 

If  the  patient  does  not  react,  or  if,  in  spite  of  the  skilful  application 
of  the  Esmarch  band,  oozing  of  blood  persists,  and  seems  to  prolong 
shock,  the  surgeon  must  consider  whether  the  mere  presence  of  the 
mangled  extremity  is  not  detrimental,  and  whether  by  resorting  to 
amputation  at  once  he  will  not  obviate  the  tendency  to  death  better 
than  by  delay.  In  such  cases  delay  is  fatal  with  extremely  few 
exceptions;  but  by  prompt  operation,  even  "under  desperate  circum- 
stances, a  life  is  occasionally  saved.  In  such  a  patient  under  my 
care  at  the  Episcopal  Hospital  (March  12,  1909),  I  amputated  the 
thigh,  and  though  the  pulse  could  not  be  felt  for  nearly  two  days 
subsequently,  recovery  ensued.  In  such  cases  speed  in  operating 
is  important;  the  time  consumed  need  not  exceed  ten  or  fifteen 
minutes. 


SPECIAL  AMI'l'TA  TIONS 


205 


SPECIAL   AMPUTATIONS. 

Amputations  of  the  Hand. — Though  removal  of  portion  of  the 
hand  is  ro(iiiire<l  frcciuciitly,  the  surgeon  should  exercise  tiie  utmost 
conservatism;  no  artificial  contrivance  can  be  as  useful  as  the  human 
hand,  and  though  amputation  of  a  portion  of  it  is  often  a  less  tedious 
and  more  brillant  oi)eration  than  partial  exicision  and  careful  suture, 
yet  judicious  attempts  at  the  latter  are  not  seldom  attended  by 
gratifying  results  (Figs.  118  and  119). 


Fig.  153. — Tendinous  insertions  in  the  middle  finger:  a,  deep  flexor;  b,  superficial 
flexor;  c,  extensor;  d,  luinbrical;  e,  exten.sor  carpi  radialis  brevior.  Note  the  uselessness 
of  the  proximal  phalanx  (2),  unless  the  insertion  of  the  superficial  flexor  tendon  is 
retained  in  the  middle  phalanx  (.3) ,  or  unless  6  is  sutured  to  c  over  the  end  of  2.  (After 
Waring.) 

Amputation  of  the  Fingers. — Xo  tourniquet  is  required,  and  local 
anesthesia  usually  is  sufficient.     This  is  secured  by  injecting  a  few 
drops  of  2  per  cent,  eucain  solution  at  four  points  around  the  base 
of  the  finger,  blocking  the  digital 
nerves.     It  is  best  to  remove  the 
fingers  at  a  joint,  but  amputation 
is   frequently    done    through    the 
proximal  or  middle  phalanx  of  the 
index    and    fifth    fingers;    this  is 
then  divided  with  a  small  saw  or 


Fig.  154. — The  finger-joints. 


Fig.  155. — Amputation  of  the  fingers 
by  the  racket-shaped  incision. 


cutting  forceps.  The  middle  and  ring  fingers  are  of  comparatively 
little  u.se,  unless  part  of  the  middle  phalanx  is  retained  (P'ig.  15.3); 
hence  it  is  better  to  amputate  at  the  metacarpal  joint  than  to  save 
only  part  of  the  proximal  phalanx,  unless  the  tendons  can  be  sutured 


206 


AMPUTATIONS 


to  each  other  over  the  end  of  the  stump.  The  position  of  the  joints 
must  be  borne  in  mind  (Fig.  154),  the  usual  error  being  to  expect  to 
find  them  too  high.  In  amputation  by  the  racket-shaped  incision 
(Fig.  155),  the  first  incision,  on  the  dorsum,  opens  the  joint,  and 
as  the  finger  is  sharply  flexed  the  lateral  ligaments  are  divided,  and 
the  palmar  flap  is  formed  by  passing  the  narrow-bladed  knife  between 
the  ends  of  the  bones  and  cutting  from  within  outward.  It  is  easier 
to  preserve  the  tendons  if  a  short  extensor  and  long  flexor  flap  are 
employed.  The  digital  arteries  are  ligated,  the  flexor  and  extensor 
tendons  sutured  to  each  other  by  buried  sutures;  and  the  stump 
is  closed  by  bringing  up  the  palmar  flap  and  suturing  it  transversely. 
This  is  known  as  the  "poor  man's  amputation"  because  the  scar  is 
carried  away  from  the  palmar  surface  and  the  stump  is  covered  with 
the  tough  palmar  skin.  If  the  palmar  surface  is  destroyed  by  disease 
or  injury,  a  dorsal  flap  may  be  used  ("rich  man's  amputation"). 
Two  lateral  flaps  are  sometimes  employed. 


Fig.  156. 


-Partial  amputation  of  right  hand  for  crush.     Everj-thing  but  the 
thumb  removed.     Episcopal  Hospital. 


In  amputation  at  the  vietacarpo-phalangeal  joints  the  oval  method 
is  to  be  preferred;  in  the  case  of  the  index  and  fifth  fingers,  the  apex 
of  the  oval  is  placed  on  the  radial  and  ulnar  borders  of  the  joint, 
instead  of  on  the  dorsum.  The  head  of  the  metacarpal  bone  of  the 
two  middle  fingers  sometimes  is  removed  for  cosmetic  reasons.  Am- 
putation of  the  thumb  is  done  by  making  a  palmar  flap  whenever  pos- 
sible. Amputations  through  the  metacarpal  bones  are  done  by  antero- 
posterior flaps,  saving  as  much  of  the  palm  as  possible,  and  making  the 
necessary  incisions  on  the  back  of  the  hand.  Owing  to  the  variety 
and  irregularity  of  the  injuries  to  the  soft  parts  and  bones  in  such 
cases,  each  one  is  a  rule  to  itself,  and  the  surgeon  must  exercise  his 
ingenuity  in  saving  whatever  may  prove  useful,  attaching  it  to  the 
stump,  and  covering  it  with  skin  flaps  in  any  way  possible  (Fig.  156). 

Amputations  through  the  wrist-joint  are  seldom  employed;  a  long 
palmar  flap  should  he  cut,  ami  the  triangular  cartilage  should  be 
retained,  so  as  to  aid  in  the  preservation  of  rotation. 

Amputations  of  the  Forearm. — In  the  lower  half  of  the  forearm 
I  think  the  circular  method  is  the  best  form  of  amputation,  while 
below  the  elbow  the  modified  circular,  with  antero-])osterior  skin 
flaps  is  quite  satisfactory  (Fig.  157).    Some  surgeons  employ  Teale's 


SPECIA  L  A  M  I'  LIT  A  TIOXS 


207 


mctlKul  above  the  wrist:  in  this  two  ri'ct an, pillar  Hai)s  arc  formed,  the 
width  of  eaeli  heiiii;  half  the  ('ircniiiference  of  the  liinl);  the  longer  flap 


Fu;.  157. — Aiitt'iinr-posterior  skin  flaps,  two  inches  Ix'low  dhow.      Episcopal  Hosj)ital. 

(formed  from  the  flexor  surface)  is  exactly  square,  while  the  shorter 
flap  is  only  one-fourth  as  long  (Fig.  158). 


Fig.  158. — Teale's  method  of  amputation. 


Amputation  at  the  Elbow. — This  may  be  done  by  the  oval  method, 
taking  a  long  skin  flap  from  the  thick  skin  covering  the  upper  part 
of  the  ulna;  or  by  antero-posterior  flaps,  the  anterior  being  longer 
and  including  the  muscular  masses  arising  from  the  condyles  as  well 
as  the  brachialis  anticus.  The  joint  is  entered  just  above  the  head 
of  the  radius. 

Amputation  through  the  Arm. — The  circular  method  is  suitable 
for  any  level  up  to  the  insertion  of  the  deltoid;  above  this  point  lateral 
flaps  are  to  be  preferred.  Injury  by  the  saw  to  the  musculo-spiral 
nerve  is  to  be  avoided  in  amputations  of  the  middle  third;  and  the 
incisions  in  the  upper  third  should  respect  the  circumflex  nerve  as 
it  enters  the  posterior  surface  of  the  deltoid.  In  cases  of  high  ampu- 
tation of  the  arm  the  tourniquet  is  applied  with  the  screw  over  the 
acromion  and  a  large  pad  in  the  axilla  over  the  vessels  which  are 
thus  compressed  against  the  head  of  the  humerus  as  the  arm  is  well 
abducted;  or  the  bloodless  method  of  Wyeth  for  amputation  at  the 
shoulder-joint  may  be  adopted. 

Amputation  at  the  Shoulder-joint. — (Morand,  before  1715.)  Hemo- 
stasia is  l)est  secured  by  Wyeth's  method  (1889):  two  long  steel 
pins  are  used,  one  entjering  in  front  of  the  acromion  and  travers- 
ing the  anterior  axillary  fold,  to  emerge  close  to  the  chest;  w'hile 
the  other  passes  from  behind  the  acromion  to  the  border  of  the 
posterior  axillary  fold,  also  close  to  the  chest.  The  points  of  these 
pins  should  be  guarded  by  sterile  corks.  An  Esmarch  band 
is  then  wrapped  tightly  three  or  four  times  around  the  shoulder, 
passing   from    above    the    acromion    around    the    armpit    between 


208 


AMPUTATIONS 


the  pins  and  the  chest  (Fig.  159).  This  band  is  effectually  pre- 
vented from  slipping  down  by  the  steel  pins,  and  the  surgeon  can 
form  his  flaps  in  any  fashion  below  them.  If  these  pins  are  not 
available,  the  surgeon  may  have  the  subclavian  artery  compressed; 
or  may  cut  down  in  the  axilla  and  do  a  preliminary  ligation  of  the 
axillary  artery  in  its  first  portion.     I  adopted  the  latter  method  in 


Fig.  159. — Wycth's  pins  applied  for 
amputation  at  the  shoulder. 


Fig.  160. — Incisions  for  amputation  at 
the  shoulder  by  Larrey's  method  (external 
racket). 


Fig.  IGl. — Incisions  for  amputation  at 
the  shoulder  by  Spence's  method  (ante- 
rior racket). 


Fig.  162. — Incisions  for  amputation  at 
the  shoulder  by  Dupuytren's  method 
(external  flap). 


one  case,  in  order  to  inject  the  brachial  plexus  with  eucain,  for  the 
purpose  of  preventing  shock  from  the  amputation ;  but  I  found,  Avhat 
is  frequently  the  case,  that  the  axillary  artery  still  bled,  when  severed 
below  the  ligature,  from  the  collateral  circulation  through  the  sub- 
scapular branch;  a  second  ligature  was  therefore  required. 

The  only  form  of  amputation  habitually  practised  at  the  shoulder- 
joint  is  the  racket  method,  though  it  has  many  modifications,  known 


SPECIAL  AMl'UTA TIONS 


209 


l)y  various  iiainos.  'I'lic  operation  of  Larrcy  (ISI7),  (external  racket 
method),  is  now  very  seldom  enii)loye(l  {V\^.  KiO).  In  Spence's  amj)U- 
tation  (lcS()7),  (anterior  racket  method)  the  incision  hejjins  midway 
between  the  acromion  and  the  coracoid,  where  the  point  of  an  oval  is 
formed,  then  passes  down  nearly  to  the  insertion  of  the  deltoid,  and 
there  encircles  the  arm  trans\'ersely  (Fi<!;.  Kil).  J)npnytren's  ampu- 
tation (1S12),  hy  a  larj^e  deltoid  flap,  ori<,anally  was  i)erformed  by 
transfixion:  the  knife  entered  at  the  front,  just  within  the  acromion, 
and  its  point  emer<i;ed  behind  at  the  level  of  the  spine  of  the  scapula; 
the  Hap  extended  down  almost  to  the  insertion  of  the  deltoid.  After  dis- 
articulation a  short  internal  Hap  was  cut  from  within  outward  (Fifij.  1()2). 
A  form  of  amputation  midway  between  these  two  extremes  (Spence 
and  Dupuytren)  may  be  termed  the  lateral  flap  method,  the  internal 
Hap  bein^j;  very  short,  and  the  external  being  formed  })y  an  incision 
beginning  as  in  Dupuytren's  and  Spence's  methods,  but  not  extending 
so  high  i)osteri()rly  as  the  former. 

Lateral  Flap  Method. — The  knife  is  entered  between  the  coracoid 
and  acromion  processes,  and  cutting  through  all  the  tissues  down 
to  the  muscle  is  carried  downward  in  a  broad  sweep,  nearly  to  the 
insertion  of  the  deltoid,  and  up  again  as  far  as  the  posterior  axillary 
fold.  The  flap  thus  marked  out  is  deepened  to  the  bone,  and  raised 
so  as  to  expose  the  tuberosities  of  the  humerus.  With  the  arm  of 
the  patient  held  close  against  his  chest,  and  rotated  out  as  far  as  it 
will  go,  the  point  of  the  amputating  knife  opens  the  capsule  by  a 
transverse  cut  between  the  acromion  and  the  tuberosities,  and  then 
detaches  the  subscapularis,  attached  to  the  lesser  tuberosity,  and 
severs  the  long  head  of  the  bi- 
ceps. The  arm  is  then  forcibly 
rotated  inward,  and  the  muscles 
attached  to  the  greater  tuber- 
osity are  severed.  The  head  of 
the  bone  then  drops  from  the 
glenoid  ca\ity,  and  may  be  fur- 
ther freed  by  cutting  the  mus- 
cles attached  to  the  bicipital 
groove.  The  amputating  knife 
is  then  passed  across  the  joint 
between  the  upper  end  of  the 
humerus  and  the  axilla,  and  the 
axillary  tissues  are  cut  from 
within  outward.  After  ligating  the  vessels  and  retrenching  the 
nerves,  the  Esmarch  band  and  the  pins  are  removed,  the  muscles  of 
the  two  flaps  are  sutured  to  each  other,  and  the  skin  closed,  Avith 
provision  for  drainage  from  the  two  ends  of  the  incision. 

This  form  of  amputation  may  be  very  quickly  performed,   and 
it  leaves  a  very  excellent  stump  (Fig.  163).     Its  advantages  are  (1) 
the  first  incision  is  the  same  as  that  used  for  excision  of  the  shoulder- 
joint,  and  permits  inspection  of  the  parts  before  the  amputation  is 
14 


Fig.  163. — Stump  resulting  from  lateral 
flap  method  of  shoulder  amimtation  (modi- 
fied Dupuytren's).     Episcopal  Hospital. 


210 


AMPUTATIONS 


performed;  (2)  the  posterior  circumflex  artery  and  circumflex  nerve 
are  not  divided,  if  the  knife  is  kept  close  to  the  bone  in  detaching 
the  deltoid  flap;  (3)  either  the  external  or  internal  flap  may  be  re- 
trenched at  the  expense  of  the  other,  in  case  of  injury  or  disease 
invading  one;  (4)  in  emergencies  the  entire  operation,  up  to  the 
division  of  the  inner  flap,  may  be  completed  almost  bloodlessly 
without  the  use  of  a  tourniquet;  and  the  main  vessels  can  readily 
be  controlled  by  the  fingers  of  an  assistant  before  the  inner  flap  is 
severed;  or  the  third  portion  of  the  axillary  artery  may  be  ligated 
through  the  first  incision,  before  raising  the  external  flap  or  dis- 
articulating; finally  (5)  it  is  more  nearly  universally  applicable  than 
any  other  method  of  shoulder-joint  amputation. 

Amputation  above  the  Shoulder. — The  interscapulo-ihoracic  ampu- 
tation   (Berger's  operation,    1887)  comprising  removal  of  the  entire 

upper  extremity,  is  employed  usually 
for  disease,  especially  sarcomas  of  the 
shoulder  or  scapula,  though  it  is  occa- 
sionally required  for  injur}'.  The  oper- 
ation is  best  performed  by  opening  the 
sterno-clavicular  joint,  raising  the  clavi- 
cle (Le  Conte,  1899),  and  detaching  the 
pectoralis  minor  from  the  coracoid ;  then 
the  subclavian  artery  and  vein  are  doubly 
ligated  outside  of  the  scalenus  anticus, 
and  divided;  the  brachial  plexus  is  next 
cut,  after  injecting  it  proximally  with 
eucain;  the  transversus  colli  and  supra- 
scapular arteries  are  ligated  and  divided, 
and  finally  the  scapula  is  dissected  away 
from  the  chest.  The  incisions  used  are 
shown  in  Fig.  164.  Berger  (1905)  col- 
lected ninety-four  cases  of  this  operation, 
with  eight  deaths,  a  mortality  of  8.5 
per  cent.;  in  the  twenty-five  cases  in  which  the  tumor  originated 
in  the  scapula  there  were  five  deaths,  and  only  three  deaths  among 
the  sixty-nine  cases  of  sarcoma  of  the  humerus. 

Amputations  of  the  Foot. — The  phalanges  may  be  amputated  by 
an  oval  incision,  with  a  plantar  flap;  or,  preferably,  by  antero- 
posterior flaps.  The  heads  of  the  metatarsal  bones  should  be 
retained  whenever  possible,  as  they  aff"ord  great  support  in  walk- 
ing. A  single  metatarsal  bone,  with  its  annexed  digit,  may  be  removed 
by  a  dorsal  incision.  Amputations  through  the  metatarsal  bones 
are  sometimes  performed  for  gangrene  following  frost-bite;  a  long 
plantar  and  short  dorsal  flap  are  used.  Amputation  at  the  tarso- 
metatarsal joint  (Lisfranc,  1815)  is  difficult  to  perform,  and  is 
seldom  employed  (Fig.  105).  To  avoid  the  difficulties  of  dis- 
articulation Hey  (1799)  sawed  off  the  projecting  internal  cuneiform, 
while  Skey  (1850)  removed  the  base  of  the   second   metatarsal  by 


Fig.  164. — Incisions    for    intersca 
pulo-thoracic  amputation. 


SPECIAL  AMI'UTA  TIONS 


211 


I'littini];  forceps.  It  is  better  to  saw  tlirougli  tlic  foot  at  any  level 
required  by  tlie  length  of  available  skin!  flaps  (Hancock).  Ampu- 
tation at  the  mcdio-tarsal  joint  (Chopart,  1792)  is  performed  thus: 
a  transverse  incision,  convex   forward,  is  made  across   the  dorsum 


Fig.  165. — The  t;irsal  joints:  .1,  astragalus;  Ca,  calcaiieuni;  <S',  scaphoid;  C,  cuboid; 
1,  2,  3,  cuneiform  bones.  Note  the  irregularity  of  Lisfranc's  joint  (between  the  tarsus 
and  metatarsus).  Chopart's  joint  is  between  the  astragalus  and  calcancum  posteriorly, 
and  the  scajjhoid  and  cuboid  anteriorly.  The  subastragalar  joint  includes  the  astragalo- 
scaphoid  joint  as  well  as  the  astragalo-calcanoan. 


of  the  foot,  from  a  jioint  midway  between  the  external  malleolus 
and  the  tuberosity  of  the  fifth  metatarsal,  to  a  point  half  an  inch 
behind  the  tubercle  of  the  scaphoid;  the  plantar  flap  extends  from 
the  same  points  as  far  forward  as  the  line 
of  the  metatarso-phala ngeal  joints.  The  usual 
error  is  to  make  this  flap  too  short.  By  for- 
cing the  foot  downward,  after  making  the 
dorsal  flap,  the  joint  between  the  calcaneum 
and  cuboid  is  easily  opened  on  the  outer  side; 
and  the  disarticulation  is  completed  by  pass- 
ing between  the  astragalus  and  scaphoid. 
Though  the  scaphoid  has  repeatedly  been 
left,  unintentionally,  it  has  not  interfered 
with  the  result.  Careful  dressing  and  after- 
treatment  are  rec^uired  to  keep  the  calf  mus- 
cles from  drawing  the  cicatrix  on  to  the  sole 
of  the  foot.  The  patient  walks  with  the 
ankle-joint  in  slight  plantar  flexion  (Fig.  166). 

Amputation  at  the  Ankle-joint  (Syme, 
1843),  including  removal  of  the  maUeoli,  is 
performed  by  making  a  heel  flap  by  cutting 
across  the  sole  from  one  malleolus  to  the 
other.  Subastragalar  amputation  (Textor, 
1841)  retains  the  motions  of  the  ankle-joint, 
and  greater  length  of  limb. 

Pirogoff's  Amputation  (1854). — In  this  oper- 
ation all  the  foot  is  removed,  except  the 
posterior  part  of  the  calcaneum,  which,  still 

attached  to  the  tendo  Achillis  and  covered  by  the  tissues  of  the  heel, 
is  brought  up  and  applied  to  the  sawn  surfaces  of  the  tibia  and  fibula 
(Fig.  167).    The  plantar  flap  is  formed  by  cutting  across  the  sole  from 


Fig.  166. — Stump  thirty- 
two  years  after  Chopart 
amputation  (in  1877)  by 
the  late  Prof.  Ashhurst. 
Episcopal  Hospital. 


212 


AMPUTATinxS 


just  in  front  of  the  external  malleolus  to  just  below  the  internal 
malleolus;  the  dorsal  flap  is  slightly  convex  forward  across  the  front 

of  the  ankle-joint  (¥i^.  168).  The 
malleoli  are  cleared,  carefully  pre- 
serving the  calcaneal  branches  of 
the  posterior  tibial  artery,  and  the 
leg  bones  are  sawed  just  above 
the  articular  surface.  The  calcis  is 
sawed  obliquely  from  above  down- 
ward and  forward.  This  amputa- 
tion preserves  almost  the  normal 
length  of  the  extremity  (lost  in 
Syme's  amputation),  but  is  diffi- 
cult to  perform,  and  makes  a  less 
useful  stump  than  Chopart's. 

Many  patients,  especially  labor- 
ing men.   prefer  to  have  ampu- 


FiG.  167. — Skiagraph  of  stump  of  Piro- 
gofiF  operation.  (Case  of  Dr.  H.  C. 
Deaver.)     Episcopal  Hospital. 


Fig.  16S. — Skin  incision  for  Pirogoflf's 
amputation. 


tation  done  at  "the  point  of  election"  in  the  leg  (a  hand-breadth 
below  the  tubercle  of  the  tibia),  instead  of  through  the  ankle  or 
lower  leg,  because  the  short  stump  is  better  adapted  for  use  with  the 
cheaj)  "peg  leg." 

Amputation  of  the  Leg. — In  the  lower  third  of  the  leg,  antero- 
posterior flaps  are  to  be  preferred.  Teale's  method  (1S58)  produces 
an  excellent  stump  (Fig.  loS).  In  the  middle  and  upper  leg  the  lateral 
flap  method  of  Sedillot  (1840)  as  modified  by  J.  Ashhurst,  Jr.  (1889), 
is  better:  The  knife  is  entered  on  the  inner  side  of  the  spine  of  the 
tibia,  and  passes  downward  for  about  three  inches,  then  curves 
backward,  outlining  a  long  flap  and  terminates  diametrically  opposite 
the  point  of  beginning;  a  short  internal  flap  is  then  formed  (Fig.  169). 
The  cicatrix  is  carried  to  the  inner  side  of  the  stump,  and  the  outer  flap 
covers  the  spine  of  the  tibia  (Fig.  170).  If  the  skin  on  the  front  of  the 
leg  is  deficient,  a  long  posterior  flap  may  be  used  (Henry  Lee,  1865), 
preferabh-  including  onlv  the  gastrocnemius  muscle  (J.  Ashhurst, 
Jr.,  ISSlj. 


SPECIAL   AMP  VTA  TIONS 


213 


Amputation  at  the  Knee.  A  distinction  is  iujhIc  hctwccn  aiiipntji- 
tions  at  the  kncc-joiiit,  which  arc  pure  disarticuhitioiis,  and  ain]>n- 
tations  at  the  knee,  in  which  a  section  is  removed  from  the  femoral 
condyles.  Two  methods  are  in  use,  a  long  anterior  flap  method,  and 
a  hiteral  Haj)  method;  the  hitter  is  more  appHcable  to  disarticulations, 
when  the  cicatrix  falls  between  the  condyles.  But  the  anterior  Hap 
metlKxris  I)(>tter  c\-en  in  such  cases.     In  disarticulations  the  i)atella 


Fig.  170. — Stump  of  leg  eight  weeks 
after  amputation  by  Ashhurst's  modifica- 
tion  of  Sedillot's  method.  Episcopal 
Hospital. 


Fig.  169. — Amputation  of  leg  by 
long  external  and  short  internal  flaps. 
(.\shhurst's  method.) 


Fig.  171. — Stokes'  osteoplastic  supra- 
condj'lar  knee  amputation,  patella  utilized : 
shaded  parts  are  those  brought  in  apposi- 
tion.    (Farabeuf.) 


should  be  retained  if  possible;  or  its  articular  surface  may  be  removed 
by  a  saw,  and  applied  to  the  sawn  surface  of  the  femoral  condyles 
(transcondylar  amputation  of  Gritti,  1857);  or  to  that  of  the  femoral 
shaft  (supracondylar  amputation  of  Stokes,  1870)  (Fig.  171). 

Amputation  of  the  Thigh. — The  circular,  modified  circular,  and 
flap  methods  all  produce  an  excellent  stump  in  the  thigh.  The  circular 
is  best  whenever  there  is  a  choice.  If  flaps  are  used,  the  posterior 
should  be  cut  sufficiently  long.     The  greater  retraction  of  muscles 


214 


AMPVTATIOXS 


in  the  posterior  flap  carries  the  cicatrix  away  from  tlie  face  of  the 
stump  '  Fii:.  172). 

Amputation  at  the  Hip-joint  ill.  Thomson  before  1777j. — Hemo- 
stasis  is  secured  by  Wyeth's  method  (1890):  Two  steel  pins  are 
used,  each  yg  of  an  inch  in  diameter,  and  ten  inches  long;  one  pin 
is  introduced  close  to  the  spine  of  the  pubis,  and  after  traversincr  the 
adductor  tendons  emerges  just  below  the  tuberosity  of  the  ischium; 
the  other  pin  enters  below  and  within  the  anterior  superior  spine  of 
the  ilium,  traverses  the  gluteal  muscles  for  about  three  inches,  and 
emerges  well  above  the  level  of  the  great  trochanter;  the  points  of 
the  pins  are  immediately  shielded  by  corks.  A  compress  of  gauze, 
two  inches  thick  and  four  inches  square,  is  laid  over  the  femoral 
vessels  at  the  brim  of  the  pelvis,  and  an  Esmarch  band  is  wrapped 
very  tightly  five  or  six  times  around  the  hip  between  the  steel  pins 
and  the  pelvis  (Fig.  173). 


Fig.  172. — Ami>utation  of   right    thigh  Fig.  17.3. — Wyeth's   pins,  and    Esmarch 

(anterior-posterior       flapsj.        Episcopal       band,  for  hemostasis  during  amputation  at 
Hospital.  the  hip-joint. 

Antero-posterior  Flap  Method  Guthrie.  1815). — The  flaps  are  cut 
from  without  inward, ^  with  a  moderately  short  knife;  the  posterior 
is  formed  first,  the  incision  commencing  above  the  trochanter,  and 
crossing  the  back  of  the  thigh  in  a  curved  line  convex  downward,  to 
a  point  in  front  of  the  tuber  ischii;  the  anterior  flap  is  then  outlined, 
extending  at  least  five  inches  below  the  joint  (Fig.  174).  These  flaps 
being  dissected  up  and  the  joint  exposed,  it  is  opened  in  front,  the  femur 
being  forcibly  abducted  and  hyper-extended,  bringing  the  ligamentum 
teres  into  view;  when  this  has  been  cut  and  the  remainder  of  the 
capsule  divided,  any  fibres  on  the  back  of  the  joint  are  severed,  and 
the  limb  removed. 

In  cases  where  Wyeth's  method  of  hemostasis  is  not  available, 

1  Guthrie  cut  them  bv  transfixion. 


SI'ECIA  L  A  MI'UTA  TIONfi 


215 


Mini  \\luT(>  M()inl)iir<,'"s  iiu'tliod  (see  below)  is  not  emi)I()yed,  the  siir- 
jreoii  iiiiiy  ado])!  either  ])reliiniiiary  lipition  of  the  femoral  vessels, 
by  ail  anterior  racket  incision  (Larrc\,  iSlTj,  o|)eniiiK  the  joint 
from  the  front  and  (Jixidin^^  the  remaining-  tissues  |)osteri«)rly  from 
within  ontward;'  or  he  may  adopt  DielVeiiijach's  method  (1827), 
consistinjj  of  eireular  ami)utation  of  the  thigh  followed  by  exeision 
of  the  head  of  the  femur  through  an  outer  longitudinal  ineision;^  or 
following  lirashear's  (1S()())  and  Fourneaux-Jordan's  (1879)  method 
as  modified  by  Semi  {\S[y.])  may  first  disarticulate  through  an  external 
incision  and  then,  i)uneturiug  the  tissues  on  the  inner  side  of  the 
thigh,  introduce  a  double  elastic  tube,  and  comi)ress  in  this  wax  the 


Fig.  174. — Incisions  for  amputation 
at  the  hip-joint  by  antero-poterior 
flaps.    (Guthrie's  method.) 


Fig.  175. — Incision  forinterilio-ahdominal 
amputation 


tissues  of  both  anterior  and  posterior  flaps  before  removing  the  limb. 
Compression  by  a  forceps  tourniquet,  somewhat  like  the  forceps  used 
for  intestinal  anastomosis,  may  also  be  employed  (Lynn  Thomas, 
1898).  The  mortality  of  hip-joint  amputation  is  now  about  8  per 
cent,  in  disease,  and  16  per  cent,  in  traumatic  cases  (Wyeth,  1910), 
this  vast  improvement  in  the  results  being  due  chiefly  to  improve- 
ments in  methods  of  hemostasis. 

1  This  is  the  "extirpation  method"  of  Kocher,  permitting  careful  dissection  of 
malignant  disease,  and  clamping  and  ligating  every  vessel  as  it  is  cut.  It  also 
permits  nerve-blocking. 

2  If  there  is  nothin?  to  contraindicate  subperiosteal  excision,  a  more  movable 
stump  will  be  obtained. 


216  AMPUTATIONS 

Interilioabdominal  Amputation  (Billrotli,  1885). — The  incisions 
used  are  shown  in  Fig.  175.  The  horizontal  and  descending  rami  of 
the  pubes  are  divided,  and  the  ilium  is  sawed  through  just  in  front 
of  the  sacro-iliac  joint,  the  entire  intervening  })()rtion  of  the  pelvis 
being  removed.  Ransohofi'  (1909)  has  collected  thirty-four  cases  of 
this  opei:9.tion,  which  is  done  almost  solely  for  malignant  disease; 
only  twelve  patients  survived  more  than  a  few  hours.  The  best 
method  of  hemostasis  is  Momburg's  (1908),  which  has  been  used 
by  both  Pagenstecher  (1909)  and  Bier  with  success,  in  interiho- 
abdominal  amputations.  This  method  of  hemostasis  had  been  em- 
ployed up  to  1909  wath  success  in  over  thirty  operations  of  various 
kinds.  It  consists  in  a])])lying  an  Esmarch  band  or  thick  rubber  tube 
(size  of  the  finger)  four  or  five  times  so  tightly  around  the  waist, 
between  costal  arch  and  iUac  crests,  as  to  stop  pulsation  in  both 
femoral  arteries;  the  band  is  applied  only  after  the  patient  is  anesthe- 
tized, and  before  it  is  removed  the  patient  is  inverted  and  an  elastic 
band  applied  around  the  base  of  each  lower  extremity,  so  as  to  prevent 
sudden  anemia  of  the  heart  when  the  waist  band  is  removed. 


CHArTKR    IX. 

EFFECTS  OF  IIFAT  AND  (OLD;  INJURIES  BY  ELE(TPvIC 

(I'UUENTS,  LKillTNING,  AND  THE   U()NT(;EX 

RAYS;  SKIN-GRAFTING  AND  JM.ASTIC 

SURGERY. 

Burns  and  Scalds.  The  effect  is  essentially  the  same  whether 
the  injury  is  prodnced  by  flame  (burn)  or  by  hot  li(ini(l  (.s-mW).  In 
scalds,  however,  the  hair  nsnally  remains  intact,  while  in  bnrns  it 
is  singed. 

Symptoms. — Local  symptoms  vary  with  the  degree  of  heat  and  the 
length  of  contact:  mere  singeing  of  the  hair  and  a  passing  erythema 
may  be  caused  by  momentary  contact  of  flame,  while  prolonged 
contact  with  some  body  at  much  lower  temperature  {e.  g.,  hot  water 
bottle)  may  produce  a  very  destructive  lesion.  Burns  may  be  classi- 
fied in  three  degrees:  (1)  Erythema.  (2)  Vesicles  and  Bullae.  (3) 
Sloughing.  The  reactionary  changes  wdiich  occur  in  the  burned  part 
are  identical  with  those  already  discussed  in  the  chapter  on  Infiam- 
m  at  ion. 


Fig.  176. — Scald  of  hand,  second  degree;  twelve  hours'  duration;  showing  bullae. 
Episcopal  Hospital. 


Constitutional  effects  of  burns  depend  much  more  on  the  area 
involved  than  on  the  depth  of  the  burn.  A  superficial  burn  may  be 
attended  by  the  gravest  consequences,  even  death,  if  extensive; 
whereas  a  very  deep  burn,  if  it  involves  only  a  small  area,  may  be 
almost  unattended  by  constitutional  symptoms.  As  in  other  injuries, 
the  constitutional  effects  of  burns  may  be  divided  into  those  of  shock 
and  reaction;  and  there  usually  follows,  in  severe  cases,  a  stage  of 
exhaustion.  The  pain  is  intense,  and  in  extensive  burns  ma\'  induce 
hyperpnea,  which,  according  to  the  theory  of  Henderson  (p.  172), 
produces  acapnia,  and  so  induces  shock;  patients  may  die  in  the  first 
stage,  without  reaction.     The  unburned  skin  is  pale,  the  patients 


218 


EFFECTS  OF  HEAT  AND  COLD 


feel  chilly,  and  require  to  be  covered  up;  the  usual  signs  of  shock 
are  present.  Often,  however,  reaction  begins  soon,  sometimes  before 
the  patient  is  seen  by  the  surgeon;  and  at  this  time  yrosiraiion 
icith  excitement  or  irauinatic  deliriniu  (p.  173)  may  dominate  the  scene. 
This  stage  lasts  for  a  week  or  more,  being  accompanied  l)y  high 
fever,  often  with  intense  congestion  of  organs  underlying  the  lesion 
(pneumonia,  in  thoracic  burns;  peritonitis,  in  those  of  the  abdomen; 
meningitis  in  those  of  the  head).  There  is  a  tendency  to  fatty  degener- 
ation of  all  organs;  the  liver,  spleen,  and  lymph  nodes  may  be  enlarged; 
the  urine  is  scanty,  of  high  specific  gravity,  or  entirely  suppressed. 
The  bile  is  believed  to  be  abnormally  toxic.     The  blood  is  prone  to 


Fig.  177. — Ulcers  resulting  from  exten- 
sive burns  received  three  months  pre- 
viously.    Episcopal  Hospital. 


Fiu.  178. — Same  patient,  two  months 
later,  after  complete  cicatrization.  Epis- 
copal Hospital. 


thrombosis,  and  capillary  embolism  is  not  infreciuent;  there  is  hyper- 
leukocytosis  and  polycythemia;  hemoglobinuria  and  albuminuria 
may  exist.  In  rare  cases  duodenal  idceration  (Curling,  1842),  with 
hemorrhage  or  perforation,  develops,  possibly  from  excretion  of 
toxic  substances  through  Brunner's  glands,  or  as  the  result  of  embo- 
lism.^ The  patient  is  excessively  thirsty,  but  constantly  vomits  what 
is  taken  into  the  stomach;  there  may  be  septic  diarrhea;  he  feels 
hot,  is  restless,  and  tosses  off  the  bed-clothes.     If  he  survives  this 


1  Alexander  (1912)   observed  this  complication  in  four    out  of    twenty-seven 
patients  with  extensive  burns. 


liURNS  AND  fiCALDS  210 

stafi;c,  tlicre  follows  that  of  cxliaiistioii,  with  lu'ctic  fever,  profuse  siip- 
])uratioii  (►f  the  wounded  surfaces,  and  |)(Tha])s  metastatic  (especially 
subcutaneous)  abscesses. 

Death  from  Bums  may  be  (hie  to  shock,  to  visceral  complications, 
to  (wIkuisIIoii,  or  to  Iwuioh/sis  and  aufo-iidoxicaiioii.  Amouj^  the 
visceral  complications  may  be  included  edema  of  the  glottis,  from 
inhalation  of  steam  or  hot  smoke.  In  fatal  cases,  death  usually 
occurs  within  forty-eight  hours. 

Prognosis.  In  local  burns  prognosis  as  to  life  is  good,  even  if  the 
part  be  much  deformed  by  subsequent  cicatricial  contraction.  Burns 
of  the  trunk  are  more  serious  than  those  of  the  extremities.  If  a  burn 
in\()lves  more  than  one-third  of  the  body  surface  it  usually  is  fatal. 
(General  burns  are  always  fatal.  Jiurns  are  i)articularly  serious  in 
infants,  the  aged,  those  of  intemperate  habits,  those  with  diseased 
kidneys,  etc. 

Treatment. — The  indications  in  all  cases  are  to  control  the  pain, 
to  coDihdt  flic  sliocli,  and  to  prevent  infection.  In  severe  cases,  where 
death  is  antici])ate(l,  the  most  that  can  be  done  is  to  ])romote  euthan- 
asia. This  is  best  accomplished  by  the  use  of  morphin  hypodermic- 
ally,  and  the  immersion  of  the  patient's  body  in  a  bath  of  saline 
solution  at  about  blood-heat.  Shock  is  combated  as  described  at 
p.  17o;  especially  important  is  the  dilution  of  the  blood  by  saline 
solution,  which  relieves  toxemia  and  restores  the  fluid  contents 
depleted  by  discharges  from  the  burned  surfaces.  Prevention  of 
infection  involves  local  treatment  of  the  lesions;  anything  which 
protects  them  from  the  air  lessens  pain,  and  in  extensive  burns  nothing 
is  so  satisfactory  as  the  continuous  bath,  which  should  be  kept  warm 
and  clean  by  frequent  change.  In  burns  of  less  extent  it  makes  little 
difference  what  dressing  is  applied,  so  long  as  it  is  aseptic,  and  absorbs 
or  does  not  dam  up  the  discharges.  Spray  the  burned  surface  lightly 
with  peroxide  of  hydrogen,  and  surgically  cleanse  the  surrounding 
parts.  Do  not  scrub  the  burns.  Open  bullae  w^ith  a  sterile  knife, 
and  let  the  epidermis  fall  back  in  place  as  the  serum  escapes.  Alex- 
ander had  occasion  to  treat  twenty-seven  burned  patients  simulta- 
neously. He  concluded  that  for  burns  of  the  first  degree  the  picric 
acid  dressing  was  best;  for  those  of  the  second  degree  he  preferred 
the  boric  acid  solution  bath,  which  was  used  for  three  hours  at  a 
time,  with  intermission  of  six  hours;  and  for  burns  of  the  third 
degree  he  recommends  the  following  ointment:  ichthyol,  gr.  xlviii; 
ol.  olivse,  foij;  lanolin,  q.  s.  ad  ,^iij.  Picric  acid  dressi)ig:  gauze  soaked 
in  1  per  cent,  aqueous  solution  is  laid  on  the  burn  and  covered  with 
absorbent  cotton,  not  with  waxed  paper,  as  evaporation  should  be 
favored;  the  dressing  is  left  in  place  four  or  five  days.  It  should  be 
used  only  over  small  areas,  as  constitutional  poisoning  has  occurred 
(Rose,  1903).  Senn's  powder  (boric  acid,  three  parts;  salicylic  acid, 
one  part)  or  Billrotlis  powder  (equal  parts  of  starch  and  zinc  oxide) 
may  be  applied  to  small  burns,  and  forms  a  scab  which  need  not  be 
removed  for  several  days.      Carron  oil,  made  by  stirring  linseed  oil 


220 


EFFECTS  OF  HEAT  AND  COLD 


and  lime  water  into  a  thick  paste,  is  very  grateful  to  the  ])atient. 
So  soon  as  granulations  have  formed,  the  burn  is  treated  as  an  ordinary 
ulcer  (p.  54). 


Fig.  179. — Sanio  patient  as  Fig.  177, 
one  year  later,  after  extensive  plastic 
operations.     Episcopal  Hospital. 


Fig.  180. — Same  patient  one  year  after 
complete  cicatrization,  showing  result  of 
extensive  plastic  operations.  Episcopal 
Hospital. 


When  much  skin  has  been  destroyed,  healing  will  be  slow,  and 
skin-grafting  should   be  employed.      Amniotic  membrane  has  given 

some  good  results  when  grafted 
on  burns.  A  very  large  granulat- 
ing surface  should  not  be  dressed 
all  at  one  time,  for  fear  of  ex- 
hausting the  patient;  it  is  better 
to  dress  half  the  burned  area  on 
alternate  days.  If  the  patient  is 
kept  in  a  hot  room  the  burned 
areas  may  be  exposed  to  the  air, 
no  dressing  being  employed.  Great 
care  must  be  exercised  by  proper 
use  of  splints,  etc.,  especially  in 
burns  about  flexures  of  joints,  to 
prevent  undue  cicatricial  contrac- 
tion;   but   in  some  cases  healing 

Ik;,  isi— Dffnnnity  from  burns  of     can  be  sccurcd  Only  as  the  result 

feet.     (Dr.  \\liart(ju's  case.)     Children's  >.  i  „^    /T7,-    „      i '-'7    „.,J 

Hospital.  or  such  a  process  {b  igs.    1  /  /  and 


F RUST-BITE 


221 


178),  iind  the  (let'orinity  must  Ix*  overcome  hy  siihsecnieiit  pliistic 
operations  (Fij^s.  179  and  ISO).  In  sexere  grades  of  det'ormity,  witli 
paiiiliil  sears  which  pre\ent  conser\ative  operations,  amputation  may 
l)e  necessary  ( I*'i,<^.  ISl ). 

Effects  of  Cold.  In  many  ways  these"  are  anah)gous  to  those 
])ro(hiced  hy  heat,  and  (U'pend  more  on  tlie  hMi<^th  of  the  exi)()sure 
than  on  the  intensity  of  tlie  cold;  moist  cold,  especially  in  a  high 
wind,  is  much  more  apt  to  ])roduce  serious  effects  than  a  still,  dry 
cold. 

Constitutional  Effects. — Among  predisposing  causes  are  hunger, 
fatigue,  alcoholism,  etc.  There  occur  ])ainful  sensations  in  the  extremi- 
ties, perhaps  chills,  followed  by  uncontrollable  lassitude,  somnolence, 
coma,  and  death  if  the  patient  is  not  roused.  The  causes  of  death 
are  cerebral  anemia  (sudden  and  progressive  chilling);  cerebral  con- 
gestion (slow  and  continuous  chilling);  or  embolism,  in  cases  of  sudden 
reheating  (Lebastard).  Persoihs  apjjarenfly  dead  should  be  kept  in 
a  cool  room,  and  treated  by  artificial  respiration  and  gentle  frictions 
with  evaporating  or  stimulating  liniments;  when  reaction  commences 
(perliaj)s  not  for  several  hours),  the  temperature  of  the  room  may 
be  raised  gradually,  stimulants  administered,  and  the  patient  wrapped 
in  blankets.  Recovery  has  followed  after  being  buried  in  the  snow 
for  eight  days  (Tedenat),  and  when  the  rectal  temperature  had  fallen 
as  low  as  74.6°  ¥.  (Xicolaysen). 


Fig.  182. — Frost-bite  of  second  degree;  duration,  four  days.     Episcopal  Hospital. 


Frost-bite. — The  local  effect  of  cold  is  analogous  to  that  of  heat, 
and  may  be  classified  in  three  similar  degrees:  Erythema,  Bullae, 
and  Eschar,  The  exposed  part,  especially  the  fingers  and  toes,  nose, 
cheeks,  ears,  or  the  penis,  becomes  first  the  seat  of  congestion,  attended 
by  some  tingling  and  pain;  soon,  however,  the  part  becomes  blanched, 
numb,  and  stiff",  and  to  all  appearances  dead.  This  stage  is  well 
exemplified  when  local  anesthesia  is  produced  by  the  ethyl  chloride 
spray.     ^Yith  proper  treatment,  the  local  destruction  may  go  no 


222  EFFECTS  OF  ELECTRIC  CURRENTS 

further;  if  this  is  neglected,  vesicles  and  bulUe  form  (Fifj.  182),  and  if 
the  cuticle  is  destroyed  and  infection  follows,  painful  ulcers  develop 
which  are  long  in  healing.  Finally,  the  freezing  may  be  so  intense 
that  a  local  slough,  or  gangrene  of  an  entire  limb  may  occur,  the 
larger  arteries  and  veins  being  thrombosed. 

Treatment  of  milder  degrees  of  frost-bite  consists  in  gentle  frictions 
with  snow  or  iced  water  until  sensation  is  restored;  the  part,  which 
now  begins  to  tingle  and  burn,  may  next  be  painted  with  silver  nitrate 
solution  (4  to  10  grains  to  the  ounce),  which  allays  these  symptoms; 
the  part  is  then  protected  from  injury  and  maintained  at  an  even 
temperature  by  absorbent  cotton.  When  gangrene  threatens,  vertical 
suspension  of  the  limb  should  be  adopted  (v.  Bergmann,  1873)  with 
immobilization  by  splints;  as  the  swelling  subsides  the  circulation 
improves.  The  resulting  sloughs  are  treated  as  advised  in  Chapter 
II.  Amputation  should  not  be  done  until  the  line  of  demarcation 
has  been  established. 

Pernio  or  Chilblain  is  a  vaso-motor  disturbance  of  the  skin  following 
previous  frost-bite  of  mild  degree.  It  develops  as  the  result  of  sudden 
variations  in  the  temperature  to  which  the  part  is  exposed.  Chilblains 
occur  in  parts  most  exposed  to  frost-bite,  and  are  especially  common 
in  the  anemic  and  run-down.  A  patient  once  affected- is  prone  to 
have  recurrence  of  chilblains  on  slight  provocation.  The  symptoms 
and  treatment  are  much  the  same  as  for  mild  degrees  of  frost-bite. 
Constitutional  treatment  should  not  be  neglected. 

Electric  Currents. — These  produce  local  effects  (electric  burns) 
and  general  effects  (electric  shocks).  The  former  are  more  severe 
the  less  the  area  of  contact,  while  severe  shocks  and  milder  burns 
follow  broader  contacts.  The  burns  do  not  differ  from  those  due  to 
other  causes,  except  in  their  extreme  slowness  in  healing;  Da  Costa 
(1910)  warns  against  use  of  corrosive  sublimate  solutions  as  very 
irritating.  Skin-grafting  usually  is  unsatisfactory,  but  a  plastic  opera- 
tion may  succeed.  The  constitutional  eflfects  of  electric  currents  are 
practically  identical  with  those  due  to  lightning  strokes. 

Lightning  Strokes. — Death  may  l)e  instantaneous.  Stunning  almost 
always  is  produced,  and  burns  frequently  exist  at  the  points  of  entrance 
and  exit  of  the  current;  they  resemble  burns  due  to  electric  currents; 
arborescent  marks,  typical  of  lightning  strokes,  are  attributed  to 
disorganization  of  blood  in  the  vessels.  Persons  apparently  dead 
may  recover  after  many  hours;  the  usual  condition  of  a  patient  just 
after  being  struck  by  lightning  resembles  that  seen  in  concussion  of 
the  brain.  Treatment  consists  in  artificial  respiration,  external  heat, 
and  other  methods  advised  for  shock  (p.  175). 

X-ray  Dermatitis. — This  affection,  carefully  studied  by  Codman 
in  1902,  is  seldom  seen  except  as  the  result  of  repeated  and  prolonged 
exposure  to  the  llontgen  rays;  before  their  danger  was  understood, 
skiagraphers  took  no  precautions  to  protect  themselves  from  exposure, 
and  a  dermatitis  affecting  the  fingers  was  not  unusual.  The  danger 
to   patients   is   extremely   slight,   especially   since   modern   methods 


SKIN-GRAFTING  223 

pcniiit  vtTV  sliort  exposures.  The  dermatitis  does  not  develop  for 
se\('ral  da\s  after  exi)osure,  and  then  is  eharaeterized  l)y  sliji;ht 
erythema,  witli  piii;mentation  and  exfoHation  of  ei)i(hTm;  a  severer 
degree  is  evideneed  hy  the  formation  of  vesicles  and  hiilhe,  while 
the  third  dej^ree  involves  a  sloui,di  of  the  entire  skin.  Eventually, 
(lystro])Jues  of  the  nails,  keratoses,  and  ej)itheli<)inas  may  occur. 

TrciitiiH'ut.  —  No  further  exi)osure  should  he  allowed,  even  if  the 
patient  thinks  himself  well  protected  hy  leaden  shields,  etc.  For 
the  intense  ])ain  which  exists  during  the  extremely  slow  casting  of 
the  slough,  alkaline  astringents  give  the  best  results.  Ointments  are 
said  to  favor  carcinomatous  changes  (Leonard).  When  these  occur, 
am])utatiou  is  necessary. 

Therapeutic  Uses  of  the  X-ray.  —  These  should  be  applied  by  an 
exi)ert  Rontgenologist  in  consultation  with  a  dermatologist.  Some 
cases  of  lu])us,  a  few  of  keloid,  and  occasionally  a  case  of  superficial 
epithelioma  may  be  cured,  at  least  temporarily,  by  periodic  exposure 
to  the  .r-rays.  Their  action  appears  to  consist  in  stimulating  an 
over-production  of  fibrous  tissue,  by  which  the  growth  of  the  cellular 
elements  is  arrested  or  abolished.  After  operation-  for  carcinoma,  and 
in  inoperable  cases,  systematic  treatment  with  the  .r-rays  may  delay 
recurrence,  diminish  pain,  and  greatly  promote  the  patient's  comfort. 


SKIN-GRAFTING. 

In  cases  of  extensive  ulcers  resulting  from  burns  or  other  causes, 
the  practice  of  skin-grafting  often  not  only  accelerates  healing,  but 
may  be  absolutely  necessary  to  bring  it  about.  For  the  grafts  to 
"take"  well,  it  is  essential  that  the  granulating  surface  approach  in 
type  to  that  of  the  "healthy  ulcer"  (p.  54).  There  are  three  principal 
methods  of  skin-grafting,  known  by  the  names  of  Reverdin  (1869), 
Thiersch  (1874),  and  Wolfe  (LS75),  or  Krause  (1893).  In  all  of  these 
methods  the  granulating  surfaces  must  first  be  ijreparcd  for  the  recep- 
tion of  the  grafts.  Roberts  (1909)  recommends  dressing  the  part 
for  several  days  previous  to  the  grafting  operation  with  gauze  soaked 
in  formaldehyde  solution  (1  to  200);  this  renders  it  sterile,  and  the 
tops  of  the  hardened  granulations  are  then  gently  scraped  off  with  a 
sharp  razor,  just  before  applying  the  grafts.  The  ulcer  is  then  washed 
with  sterile  saline  solution  to  remove  the  antiseptics.  The  slight 
bleeding  is  checked  with  pressure  by  sterile  gauze.  The  best  sites 
from  which  to  obtain  grafts  are  the  adductor  surfaces  of  the  thigh, 
the  inner  surfaces  of  the  upper  arms,  and  the  lateral  abdominal  and 
thoracic  walls;  hairy  skin  is  not  suitable  for  grafting,  as,  apart  from 
the  deformity  which  might  result  from  reproduction  of  the  hair, 
it  is  difficult  to  sterilize  and  less  apt  to  grow  successfully  than  more 
delicately  formed  skin.  The  region  from  which  the  grafts  are  taken 
also  must  be  prepared  as  for  an  aseptic  operation.  Antiseptic  methods 
are  not  successful. 


224 


SKIN-GRAFTING 


Reverdin's  Method. — Minute  particles  of  the  cuticle  are  raised 
on  the  point  of  a  needle,  cut  off  with  a  sharp  scalpel,  and  at  once 
transferred  to  the  granulating  surface,  previously  prepared.  As 
many  such  grafts  as  may  be  required  (a  score  or  more)  are  a])plied 
over  the  ulcer,  with  the  epidermic  side  upward,  at  close  intervals; 
gently  pressed  down  on  the  granulations,  and  held  in  place  by  strips 
of  rubber  tissue;  space  should  be  left  between  the  rubber  strips,  to 
permit  escape  of  discharges,  and  these  are  absorbed  in  sterile  gauze 
dressings  held  in  place  by  a.  light  bandage.  The  part  is  suitably 
splinted,  and  need  not  be  dressed  for  four  or  five  days,  when  it  will 
be  found  that  many  of  the  grafts  have  taken,  and  may  be  recognized 
as  minute  islets  of  bluish-white  epiderm  growing  in  the  centre  of  the 
granulating  area  (Fig.  183).  In  time  these  islets  coalesce,  and  a  number 
of  small  ulcers  surrounded  by  epiderm  replace  the  one  large  surface. 


Fig.  183. — Skin-grafting  by  Reverdin's  method,  in  a  case  of  burns  of  leg.     The  white 
spots  on  the  surfaces  of  the  ulcers  are  islets  of  new-formed  skin.    Episcopal  Hospital. 

Thiersch's  Method. — Long  strips  of  epiderm,  with  only  the  most 
superficial  layer  of  the  cutis,  are  cut  by  means  of  a  ^'ery  sharp  razor, 
with  a  rapid  sawing  motion,  while  the  skin  is  held  taut.  The  skin 
and  the  razor  should  be  moistened  with  saline  solution,  to  facilitate 
the  process.  The  long  grafts  are  then  at  once  transferred  to  the 
granulating  surface,  pre^'iously  prepared,  and  spread  in  place,  covering 
nearly  its  entire  surface.  Dressing  is  similar  to  that  for  the  Reverdin 
method.  Thiersch  grafts  are  more  difficult  to  cut,  require  a  general 
anesthetic,  and  are  less  apt  to  grow  than  the  smaller  grafts  of  Rever- 
din; but  if  they  do  grow,  the  healing  of  the  ulcer  is  very  much  more 
rapid,  and  the  resulting  scar  less  conspicuous. 


Fig.  184. — Ulcer  from  compound  fracture.    Wolfe  skin-grafts  from  amputated  leg. 

Episcopal  Hospital. 


PLASTIC  SURdEHY  225 

Wolfe-Krause  Method.  Tlu'  iMitire  thickness  of  the  skin  is  trans- 
planted, l)nt  witliont  any  snhentaneons  tissue.  Tlie  j^ral'ts  may  he 
ohtained  from  the  i)atient's  own  hody,  or  from  the  health\'  tissues 
of  a  recently  amputated  hmh.  As  a  rule,  pieces  an  inch  in  diameter 
are  large  enoujjh,  leaving  space  for  discharges  from  the  ulcer  (Fig. 
184).  The  entire  operation  should  he  dry,  and  al)solutel\-  asej)tic. 
Wolfe  grafts  may  also  he  applied  to  the  wound  at  the  time  of  oper- 
ation, and  are  i)referal)le  for  such  use  to  Thiersch  grafts,  which  latter 
are  hetter  suited  for  apjilication  to  granulating  surfaces. 

PLASTIC  SURGERY. 

The  object  of  plastic  surgery  {anaplastii)  is  to  restore  or  to  improve 
the  function  or  appearance  of  a  part,  deficient  congenitally,  or  through 
disease  or  injury,  lentil  within  a  few^  years  its  field  was  limited  to 
the  skin  and  subcutaneous  tissues  (including  mucous  mem})ranes), 
but  recently  the  formation  of  new  joints  (p.  471),  transplantation 
of  bone  (p.  504),  etc.,  have  been  done.  Cinematoplastic  amputations 
(p.  202)  and  prosthesis  by  subcutaneous  use  of  paraffin  (p.  G20)  are 
parts  of  plastic  surgery,  as  are  certain  operations  on  the  female 
perineum  and  vagina  (Chapter  XXIX).  Its  more  limited  field  alone 
will  be  discussed  here. 

The  operation  consists  essentially  in  shifting  flaps  of  skin  and 
subcutaneous  tissue,  attached  by  one  or  more  pedicles,  so  as  to  cover 
in  defects  left  by  excision  of  morbid  structures.  Such  operations  will 
not  succeed  unless  asepsis  is  maintained,  and  unless  no  active  disease 
exists  in  the  parts  on  which  the  operation  is  done.  Lupus  and 
syphilitic  ulcerations  must  be  healed,  and  the  disintegrating  process 
at  a  standstill  before  any  plastic  surgery  is  attempted.  Another 
maxim  of  extreme  importance  in  plastic  surgery  is  to  do  too  little 
rather  than  too  much  at  each  step  of  the  operation,  which  is  thus 
often  better  divided  into  several  sittings. 

Plastic  operations  may  be  classified  as  follows: 

1.  Anaplasty  by  simple  approximation,  as  after  excison  of  any 
tumor  in  which  the  wound  edges  can  be  brought  together;  in  the 
operation  for  hare-lip,  etc. 

2.  Anaplasty  by  transfer  of  flaps  from  the  immediate  neighborhood, 
by  gliding,  stretching,  etc.,  as  in  operations  for  deforming  cicatrices 
from  burns,  and  in  the  Indian  method  of  rhinoplasty  (p.  (V21). 

3.  Anaplasty  by  transfer  of  flaps  from  a  distance: 

(a)  Bv  o?ie  migration,  as  in  the  Italian  method  of  rhinoplastv 
(p.  621)- 

(b)  By  successive  migrations  (method  of  Roux),  as  from  the  abdomen 
to  the  arm,  and  then  from  the  arm  to  the  face. 

4.  Anaplasty  by  readjustment  of  totally  severed  parts,  including  skin- 
grafting,  transplantation  of  bones,  joints,  etc. 

The  simpler  the  operation  the  more  successful  it  is  likely  to  be; 
hence  the  simpler  methods  always  should  be  tried  first,  unless  mani- 
15 


226  PLASTIC  SURGERY 

festly  inadequate.  Cicatricial  tissue  usually  should  be  excised  and 
not  employed  in  plastic  surgery,  as  it  is  very  apt  to  slough.  Occa- 
sionally, however,  where  a  fold  of  cicatricial  tissue  exists  (as  in  the 
knee  or  elbow)  it  will  be  possible  to  split  it,  forming  two  flaps;  and 
if  the  splitting  be  done  by  a  Z-shaped  incision,  on  straightening  the 
limb  two  lax  flaps  will  be  available  to  cover  in  the  flexure  of  the 
joint.  In  all  plastic  operations  great  gentleness  should  be  used  in 
manipulation;  strict  hemostasis  by  the  finest  ligatures  must  be  secured; 
and  accurate,  but  not  too  tight  coaptation  must  be  procured.  The 
flaps  should  contain  a  moderate  amount  of  subcutaneous  tissue  and 
their  bases  should  be  broad  and  should  contain  the  main  vascular 
supply;  and  the  flaps  should  be  made  of  sufficient  size,  especially 
when  cut  from  tissues  naturally  lax  (neck,  scrotum),  as  in  them 
retraction  is  greatest.  When  flaps  are  transferred  from  a  distance, 
or  when  the  base  of  the  flap  is  much  twisted  in  adjustment,  the  base 
must  be  divided  (to  restore  contour)  in  from  one  to  three  weeks  after 
the  first  stage  of  the  operation. 

Diagrams  illustrating  the  commoner  varieties  of  plastic  operations 
are  given  in  Chapter  XIX. 


CHAPTER    X. 
SURGEin'  OF  THE  BLOOD  VASCULAR  SYSTEAL 

Hemorrhage.  This  is  tlic  natural  couscciiu'iicc  of  injuries  which 
sever  the  walls  of  bloodvessels.  Hemorrhage  may  l)e  apparent, 
when  it  occurs  in  an  open  wound;  or  concealed  {internal),  when  it 
takes  place  into  one  of  the  natural  cavities  of  the  body.  Suhndaneous 
hemorrhagic  attended  l)y  extravasation  or  formation  of  a  hematoma, 
has  i)een  mentioned  at  p.   HiO. 

The  signs  of  hemorrhage  are  both  local  and  constitntional .  The 
local  signs  of  venous  and  arterial  hemorrhage  are  different,  but  the 
constitutional  signs  are  identical.  Venous  hemorrhage  is  characterized 
by  the  darker,  bluish  color  of  the  blood;  by  its  flowing  in  a  steady 
stream,  not  in  spurts;  and  in  most  cases  of  wounds  of  the  extremities 
by  the  ease  with  which  it  is  arrested  simply  by  elevation  of  the  part. 
.Arterial  hemorrhage  occurs  in  rhythmic  jets,  and  the  blood  usually 
is  of  a  distinctly  redder  tinge. 

Constitutional  Signs  of  Hemorrhage. — As  the  \olume  of  blood  within 
the  vascular  channels  is  rapidly  lessened  by  hemorrhage,  the  heart 
begins  automatically  to  pulsate  more  quickly.  A  steady  rise  in  the 
pulse  rate  is  one  of  the  surest  signs  of  hemorrhage.  As  the  quantity 
of  blood  in  the  system  decreases,  faintness  comes  on:  there  is  thirst, 
rapid  and  sighing  respiration  (air-hunger);  the  skin  becomes  blanched 
and  clammy;  the  lips  and  conjunctivae  are  pale;  the  ears  ring;  vision 
fails;  specks  and  blackness  float  before  the  eyes;  restlessness  and 
delirium  come  on;  involuntary  dejections  may  occur;  and  with  one 
or  two  gasps  the  patient  may  seem  dead.  At  this  stage  bleeding 
may  cease  spontaneously,  owing  to  the  diminished  force  of  the  circula- 
tion which  permits  thrombosis;  but  it  may  begin  again  when  reaction 
sets  in.  After  very  severe  or  repeated  hemorrhages,  faintness  is 
prone  to  recur;  and  the  patient  may  be  feverish  and  delirious  for 
several  days.  Slow  hemorrhage  is  much  less  serious  than  profuse, 
sudden  bleeding.  Patients  in  early  adult  life  bear  hemorrhage  better 
than  infants  or  the  very  old;  and,  as  a  rule,  women  bear  it  better 
than  men. 

Hemophilia  is  the  name  given  to  an  obscure  condition  affecting 
males  almost  exclusively,  and  seemingly  transmitted  from  one  gener- 
ation to  another  only  through  the  female  sex.  It  is  characterized  by 
an  abnormal  and  inveterate  tendency  to  hemorrhage  even  from  the 
most  trifling  injuries.  Mere  scratches,  the  extraction  of  a  tooth, 
etc.,  frequently  have  caused  such  persons  to  bleed  to  death.  The 
vice  appears  to  reside  in  a  loss  of  coagulability  of  the  blood,  though 


228  SURGERY  OF  THE  BLOOD   VASCULAR  SYSTEM 

it  was  long  held  that  the  bloodvessel  walls  were  at  fault.  Blood 
oozes  in  profusion  from  the  capillaries,  and  no  local  remedies  are  of 
much  avail.  The  internal  administration  of  calcium  chloride  may 
be  tried;  and  the  hypodermic  injection  of  horse  or  rabbit  serum,  and 
even  of  diphtheria  antitoxin  has  been  used  in  some  cases  with  benefit. 
Nolf  and  Herry  (1910)  secured  arrest  of  the  bleeding  in  nine  cases 
by  a  single  hypodermic  injection  of  10  c.c.  of  a  5  per  cent,  solution 
of  peptone  in  0.5  per  cent,  sodium  chloride  solution.  This  can  be 
sterilized  by  boiling.  Hypodermoclysis,  intravenous  injections  of 
saline  solution,  and  even  direct  transfusion  of  blood  may  be  tried. 
Plate  II,  Fig.  2,  shows  the  subcutaneous  hemorrhages  which  followed 
the  insertion  of  needles  for  hypodermoclysis  in  a  patient  with  hemo- 
philia following  circumcision;  in  this  case  recovery  occurred  after  the 
direct  transfusion  of  blood  and  use  of  diphtheria  antitoxin.  Yet  a 
year  later  the  patient  was  again  in  the  ward  with  hemarthrosis  (p. 
387)  following  a  trifling  contusion  of  the  knee. 

Spontaneous  Arrest  of  Hemorrhage. — As  mentioned  above,  bleeding 
sometimes  ceases  spontaneously.  IMost  very  small  vessels  cease  to 
bleed  in  a  few  minutes.  In  the  case  of  capillaries,  swelling  of  the 
endothelium  occludes  the  lumen;  in  larger  vessels  there  occur  in 
addition  contraction  and  retraction  of  the  vessel  walls.  Contraction 
of  a  divided  vessel  is  said  to  be  an  effort  to  restore  the  blood  pres- 
sure to  normal.  Retraction  results  from  the  natural  elasticity  of  the 
vessel,  its  ends  being  drawn  back  among  the  tissues,  and  its  walls 
curling  upon  themselves  so  as  to  diminish  the  lumen,  thus  favoring 
coagulation. 

Treatment  of  Hemorrhage. — Temporary  control  of  hemorrhage 
usually  can  be  secured  by  direct  pressure  against  the  bleeding  point, 
or  on  the  main  vessel  of  the  part  close  above  the  wound,  with  eleva- 
tion of  the  wounded  part.  When  possible  a  tourniquet  or  Esmarch 
band  (p.  193)  can  be  applied.  For  permanent  control  of  hemorrhage 
the  surgeon  has  many  means  at  his  command. 

1.  Position. — Elevation  of  the  part  has  been  mentioned  already, 
and  should  never  be  neglected.  It  is  a  remedy  so  simple  that  it 
often  is  overlooked.  Hold  the  wounded  extremity  up  in  the  air  until 
help  arrives,  if  you  can't  do  anything  else. 

2.  Pressure. — Direct  pressure  on  the  wounded  vessel  always  can 
be  relied  on  to  check  hemorrhage.  Use  your  finger  if  you  have  noth- 
ing else.  A  graduated  compress  may  be  held  against  the  wounded 
vessel:  this  is  made  of  pieces  of  gauze  so  cut  as  to  form  a  pyramid 
when  placed  one  on  the  other;  the  apex  of  the  pyramid  is  placed 
against  the  wounded  ^'essel,  and  the  compress  is  held  in  place  by  a 
tight  bandage.  Hyperflexion  of  the  elbow  or  knee  over  a  compress 
will  control  bleeding  below.  Hemostatic  forceps  (Fig.  140)  or  other 
form  of  clamp  may  be  applied  directly  to  the  wounded  vessel,  and 
in  emergency  the  forceps  may  be  left  in  place  thirty-six  to  forty- 
eight  hours.  If  the  wound  in  the  vessel  cannot  be  found,  com- 
press the  main  artery,  when  possible,  at  a  higher  point.     This,  and 


PLATE   II 


Fig.  1. — Multiple  nevi,  affecting  scalp,  forehead,  left  foot,  etc.,  in  a  baby  aged 
Si^nnonths.     Episcopal   Hospital. 

Fig.  2.  —  Hemophilia,  two  days  after  circumcision,  in  a  boy  aged  8  years;  shovving 
subcutaneous  hemorrhages;  that  in  right  thigh  followed  an  attempt  to  give  hypo- 
dermoclysis.     Episcopal   Hospital. 


TliKATMEST  OF   IIKMORUII ACE  229 

elevation  of  the  ])art,  will  arrest,  temporarily,  any  heiiiorrliaf^c.  Or 
the  woiiiul  ina\'  he  packed  with  ^aiize  or  lint.  Acupressure,  (Sir  .1.  Y. 
Siinj)soii,  IS.');))  is  seldom  emj)loyed  at  i)resent.  A  lonj^  and  strong; 
steel  pin  is  j)assed  under  the  \essel,  o('chidin<i:  it  a<;ainst  the  overlying 
tissues,  as  the  stem  of  a  flower  is  pimied  against  the  eoat  lapel;  or  a 
ligature  in  figure-of-eight  fashion  may  be  wound  around  the  two  ends 
of  the  pin.  compressing  the  vessel  between  the  pin  and  the  intervening 
tissues.  Farci pressure  or  (incieiofrip.si/  consists  in  occluding  the  bleeding 
\essels  by  powerful  clamps  which  are  remo\ed  at  once;  they  eause  a 
reactive  inlhunmation  which  will  occlude  the  lumen.  Skene  (1897) 
and  A.  J.  Downes  (1902)  used  an  electro-thermic  angeiotribe. 

o.  IIkat  and  Cold  are  efficient  in  hemorrhage  of  mild  degree. 
Cloths  wrung  out  of  very  hot  water  (120°  F.)  applied  to  the  face  of 
an  oozing  wound  (p.  190)  usually  check  all  cai)illary  bleeding.  Cold, 
in  the  form  of  ice  caps,  frequently  is  employed  in  gastric  and  intestinal 
hemorrhage;  and  often  is  of  value  in  checking  extravasation  in  the 
subcutaneous  tissues.  The  actual  cautery,  heated  to  a  black  heat 
only,  is  very  efficient  when  other  methods  are  not  available. 

4.  Styptics  are  seldom  used  except  for  oozing.  Alcohol  is  not 
very  active.  Alum,  tannic  acid,  the  perchloride  and  persulphate  of 
iron,  etc.,  are  more  valuable,  especially  when  applied  on  a  graduated 
compress.  Cocain  and  epinephrin  are  employed  on  mucous  mem- 
branes. 

5.  Torsion. — A  bleeding  vessel  may  be  caught  in  forceps  and 
twisted  on  itself  until  the  forceps  is  twisted  off  ("free  torsion";;  or, 
being  caught  higher  up  by  one  forceps,  may  be  twisted  by  another 
("limited  torsion").  In  either- case  the  manoeuvre  succeeds  in  ap- 
proximating the  walls  of  the  vessel  and  in  arousing  sufficient  reaction 
on  the  part  of  the  intima  to  favor  permanent  occlusion.  Vessels  of 
moderate  size  only  should  be  treated  by  torsion;  usually  from  five 
to  six  turns  are  sufficient. 

6.  Ligation. — Ligatures,  like  sutures,  are  of  absorbable  or  non- 
absorbable material.  Lsually  catgut  ligatures  are  preferred,  and 
for  large  vessels  chromicized  catgut  is  used,  though  some  surgeons 
prefer  silk  or  linen.  \Yhen  a  ligature  is  applied  to  a  vessel  it  constricts 
it  concentrically,  crumpling  its  coats  more  or  less,  and  bringing 
intima  into  contact  with  intima;  owing  to  the  properties  of  this 
serous  surface,  like  that  of  the  peritoneum,  pleura,  etc.,  prolonged 
contact  after  \'ery  moderate  injury  is  sufficient  to  secure  firm  adhesion. 
It  is  not  usually  necessary  to  draw  the  ligature  so  tight  as  to  rupture 
the  inner  and  middle  coats;  it  is  sufficient  to  occlude  the  vessel. 
The  method  of  union  after  firm  apposition  of  the  intima  is  patholog- 
ically identical  with  that  already  described  in  connection  with  the 
repair  of  wounds  as  union  by  adhesion.  The  walls  of  the  vessel, 
with  their  endothelial  cells,  play  a  more  important  part  in  the  process 
than  the  contained  blood;  indeed,  it  is  denied  by  some  pathologists 
that  the  blood  takes  any  part  in  the  process.  The  formation  of  a 
clot  is  not  a  necessary  phenomenon,  and  if  infection  be  absent  firm 


23()  SURGERY  OF  THE  HLOOh   VASCULAR  SYSTEM 

occlusion  of  vessels  will  rxcur  without  any  thrombosis;  this  renders 
it  safe  (Guyon,  18(f>8;  Wyeth,  1876j,  though  not  always  expe/lient, 
to  ligate  large  trunks  close  to  the  origin  of  branches,  or  tice  versa. 
Usually,  however,  a  clot  forms  proximal  to  the  ligature,  and,  if  the 
vessel  has  been  tierl  in  its  continuity  ii.  e.,  in  cases  where  the  vessel 
has  not  been  divided j,  a  smaller  clot  usually  forms  on  its  distal  side. 
These  clots  lie  rather  loosely  in  the  channel,  and  are  gradually  con- 
verted into  fibrous  connective  tissue  by  organization  (p.  '40).  Should 
such  a  clot  extend  from  the  point  of  ligation  past  the  origin  of  a  large 
branch,  there  might  be  danger  of  emboli  being  carrie^^l  away  from  it; 
hence  it  usually  is  considered  proper  not  to  apply  a  ligature  within 
an  inch  or  so  of  a  large  branch. 

Rule^  for  Ligation  of  Wounded  Arteries. — ^These  rules  are  now  classic 
in  surger>-,  and  even  today  admit  of  verj-  few  exceptions: 

1.  In  cases  of  primary  hemorrhage  do  not  ligate  the  vessel  unless  it  is 
actually  bleeding  at  the  time.  This  rule  applies  to  primarj',  not  to 
secondary'  hemorrhage,  and  should  be  obserxed  because:  (a)  bleeding 
may  never  recur;  ib)  it  Is  difficult  to  know  which  arter>-  to  tie  unless 
the  surgeon  sees  it  bleed;  and  (c)  search  for  the  artery'  may  cause 
unnecessary'  damage  and  lead  to  infection.  Exceptions:  (a)  if  the 
arterj'  is  seen  pulsating  in  the  wound  it  should  be  tied  whether  it 
bleeds  or  not:  the  operation  is  easy,  harmless,  and  the  remedy  siu-e; 
(6)  if  the  patient  has  to  be  transported  a  long  distance  or  will  be  out 
of  reach  of  a  skilful  surgeon,  it  will  be  proper  to  make  a  search  for 
the  vessel  even  if  it  is  not  bleeding  nor  easily  found. 

2.  The  vessel  should  be  ligated  where  it  bleeds  and  not  elseichere, 
no  matter  what  the  condition  of  the  wound.  Because:  (a)  unless  the 
wounded  vessel  itself  Is  seen,  the  surgeon  may  ligate  the  wrong  vessel 
and  fail  to  check  the  bleeding;  (6)  ligation  even  of  the  proper  vessel 
at  a  higher  point  will  not  prevent  recurrence  of  bleeding  from  the 
distal  end,  nor  from  the  proximal  end  if  a  large  branch  intenenes, 
so  soon  as  the  collateral  circulation  is  established.  There  are  no 
exceptions  to  this  rule  (Guthrie,  1815;  Matas,  1909j.  But  in  certain 
regions  (floor  of  the  mouth,  pehis)  it  may  be  necessarj'  to  expose 
the  bleeding  point  by  a  counter-incision,  instead  of  through  the 
original  wound. 

3.  Both  ends  of  the  wounded  vessel  should  be  ligated;  and  if  it  is 
only  partly  severed  a  ligature  should  be  applied  each  side  of  the  wound 
and  the  artery  then  divided  between  them.  Because:  when  collateral 
circulation  develops  bleerJing  from  the  distal  end  will  occur  even  if 
this  is  not  bleeding  when  the  proximal  is  ligated.  Exceptions:  (a) 
when  the  distal  end  cannot  be  found,  the  wound  should  Ix*  packed 
after  ligation  of  the  proximal  end ;  and  (b)  where  both  ends  are  easily 
found,  where  the  injurj-  was  a  clean  incised  wound,  and  where  occlu- 
sion of  the  the  vessel  might  cause  gangrene,  an  attempt  at  circular 
arteriorrhaphy  (p.  234)  should  be  made. 

4.  Wound  of  a  large  vessel  near  its  origin  requires  ligation  of  the 
wounded  vessel  below  the  wourul,  and  of  the  parent  trunk  above  and 


TliF.ATMKSr  or   IIKMOiaHIMiE  I'.W 

hcliiir  the  orifiln  of  the  icunudcd  hnnicli  ( I'Mu'.  IS'));  mikI  iroinid  of  a 
main  irunk  ucar  ilw  orujin  of  <i  Uirijc  hrancli  ni/iurr.s-  Ikju'ioii  of  the 
icoiindrd  vcssfl  (ihorc  mid  ht'loir  Ilw  iroiiiid  itiid  iKjdIion  of  Ihc  Idrf/c 
hraurh  (Fig.  ISli).  Htcdiisc:  in  the  lormcr  case  tlic  end  ol"  tl)e 
bleeding  vessel  next  the  main  trnnk  is  too  short  to  hold  a  ligature; 
and  in  the  second  ease  the  estahlishnient  of  collateral  circulati<»n 
will  cause  the  branch  to  bleed  through  the  wound  of  the  main  trnnk 
unless  the  branch  is  ligated.  Exec ))i ion:  in  case  of  the  main  vessels 
(carotid,  iliac,  femoral,  popliteal),  occlusion  of  which  may  cause 
gangrene,  the  wound  in  the  main  trunk  should  be  sutured,  and  only 
the  collateral  should  l)e  ligated. 


Fkj.  IS.j. — \\'oun(l  of  ;i  largo  liranch  noar 
its  (laroiit  trunk  rtMiuircs  lifiatiDii  of  the 
trunk  above  and  below  the  branch  as  well 
as  of  the  liranch. 


Fig.  l.Sti. — Wound  of  a  main  trunk 
near  theori^jin  of  a  large  Ijranch  recjuires 
ligation  of  the  branch  as  well  as  of  the 
trunk. 


Mtiliod  of  Ligating  Arteries. — Arteries  (and  veins)  may  be  ligated 
in  continuity  or  at  the  seat  of  the  lesion.  In  the  latter  case,  the 
cut  end  is  grasped  with  a  hemostat,  drawai  slightly  out  of  its  sheath 
and  the  ligature  applied  well  above  the  forcejjs.  When  ligation  is 
done  in  contiiuiity,  an  incision  is  made  slightly  oblique  to  the  known 
course  of  the  vessel,  the  proper  muscular  interspace  is  found,  and 
when  the  sheath  of  the  artery  is  exposed,  it  is  picked  up  by  forceps 
and  cautiously  divided  by  the  edge  of  the  knife  cutting  toward  the 
forceps  (Fig.  187).  The  threaded  aneurysm  needle  is  then  gently 
insinuated  between  the  artery  and  its  sheath  (entering  on  the  side 
where  lies  the  most  dangerous  structure,  usually  a  vein),^  and  is 
gradually  teased  around  the  artery,  great  care  being  exercised  not 
to  separate  the  sheath  more  extensively  from  the  vessel  than  is 
absolutely  necessary  and  not  to  include  a  neighboring  nerve  in  the 
ligature.  When  the  point  of  the  aneurysm  needle  emerges  on  the 
opposite  side  of  the  artery,  the  loop  of  the  ligature  lying  in  the  con- 
cavity of  the  needle  is  caught  in  forceps  and  pulled  through  (Fig.  187). 
Then  the  aneurysm  needle  is  withdrawn.  An  assistant  then  feels 
for  the  pulsation  of  the  artery  or  its  main  branches  below,  and  the 
surgeon  temporarily  constricts  the  artery  between  the  ligature  and 


'  Venae  coniifos  may  bo  tied  in  with  their  artery. 


232 


surgehy  of  the  blood  vascular  system 


his  finger,  determining  whether  lie  is  about  to  tie  the  proper  vessel 
by  its  effect  on  the  pulse  below.  In  the  case  of  anomalous  high 
division  of  the  brachial  artery,  for  instance,  he  might  be  tying  only 
one  branch  instead  of  the  main  trunk,  as  desired;  and  unless  obliter- 
ation of  the  radial  and  ulnar  i)ulse  was 
sought  for,  his  error  might  pass  undis- 
covered at  the  time.  Arteries  of  ordi- 
nary size  are  to  be  tied  with  the  square 
knot  (Fig.  114);  very  large  arteries 
(innominate,  iliac,  femoral)  or  those 
which  are  atheromatous,  are  more 
safely  secured  by  the  stay  knot  of 
Ballance  and  Pxlmunds  (Fig.  188). 


Fig.  187. — Ligation  of  an  artery; 
above,  the  sheath  is  being  opened;  in 
the  centre,  the  ligature  is  being 
passed;  below,  it  is  being  tied. 


Fig.  188. — The  stay-knot.  A,  double  ligature 
passed  and  each  end  tied  separately;  B,  all  four 
ends  tied  as  if  they  formed  one  ligature. 


Secondary  Hemorrhage. — This  was  defined  and  its  causes  stated  at 
p.  1 77.  It  is  apt  to  come  from  the  distal  stump  of  a  vessel  ligated  in  con- 
tinuity, and  is  frequently  ushered  in  by  slight  blood-stained  discharges, 
premonitory  of  the  violent  gush  when  the  ^■essel  finally  gives  way. 

Treatment. — The  treatment  differs  in  some  respects  from  that 
proper  for  primary  hemorrhage.  The  first  rule  given  above  does 
not  apply,  because  hemorrhage  having  once  recurred  is  extremely 
liable  to  do  so  again  unless  active  measures  are  instituted.  The 
surgeon  may  after  the  first,  and  must  after  the  second  bleeding  adopt 
determined  measures  to  prevent  a  return  of  the  hemorrhage  (Erich- 
sen,  1861),  and  should  ligate  both  ends  of  the  wounded  artery  in  the 
wound,  no  matter  what  the  condition  of  that  icound,  whether  or  not  active 
bleeding  is  present  ichen  the  operation  is  undertaken.  Should  re-ligation 
be  impossible  (as  in  vessels  at  the  root  of  the  neck,  or  in  the  pelvis), 
a  graduated  compress  may  be  applied;  or  neighboring  collaterals 
may  be  ligated,  to  check  the  return  circulation  (e.  f/.,  the  vertebral 
in  secondary  hemorrhage  after  ligation  of  innominate.)^  If  secondary 
hemorrhage  recurs  after  re-ligation  in  continuity,  amputation  should 
be  done  at  the  site  of  ligature  in  the  lower  extremity;  while  in  the 
upper  extremity  this  final  step  sometimes  may  be  obviated  by  ligating 


1  Secondary  hemorrhage  recurring  from  an  amputation  stump  requires  re-ampu- 
tation if  ligation  of  the  main  trunk  of  the  limb  has  failed. 


WOUNDS  or  nLOODVESSELS 


233 


tlic  main  vessel  (hnicliial,  axillary,  or  suhclaxiaii)  at  a  hi<fher  point. 
Ill  the  lower  extremity  such  a  course  would  surely  cause  gangrene, 
so  amputation  is  better. 

Constitutional  Treatment  of  Hemorrhage. — This  is  very  much  the 
same  as  that  for  shock  (|).  17.")),  csjx'cjally  \ahial)le  l)eiii<f  ele\'ation 
of  the  pelvis  and  lower  extremities,  autotranst'usion,  intravenous 
saline  infusion,  direct  transfusion  of  hlood,  and  the  administration 
of  cardiac  stimulants. 

Subcutaneous  Injuries  of  Bloodvessels.  Injuries  of  either  arteries 
or  \-cins  are  attciuh'd  hy  rcactixc  phenomena  which  correspond 
l)athologicalIy  to  the  inflammatory  process.  In  cases  of  contusion 
this  reaction  may  cause  thrombosis  of  the  hlood  within  the  vessels; 
hut  far  more  frequently  the  vessel  is  ruptured  suhcutaneously,  caus- 
ing; the  formation  of  a  hematoma  (p.  loD).  This  may  he  absorbed 
if  small,  but  sometimes  remains  fluid,  may  become  infected  (through 
the  blood-stream,  from  a  neighboring  viscus,  or  from  the  deeper 
skin  cocci),  and  recpiire  opening  and  drainage.  If  a  hematoma  pro- 
gressively increases  in  size  after  its  formation,  it  is  probable  that  a 


Fig.  ls'.t.--(  laiiLn-ciic  t'MiiMwu 
ill  Hunter's  caiia 


atidii  of  lidtli  cndsuf  niijturc(l  fi'inoral  aitcry  and  vein, 
Aniimtation.     Keeovfij-.     Eiiiscojjal  Hos^jiital. 


large  vessel  is  ruptured;  it  will  then  be  proper  to  open  the  hematoma 
and  check  the  hemorrhage.  A  hematoma  due  to  rupture  of  a  large 
vessel  may  cease  to  grow  and  finally  become  encysted,  still  being 
in  commimication  with  the  source  of  hemorrhage:  if  this  was  a  vein, 
a  so-called  venous  aneurysm  is  formed;  if  an  artery,  a  circumscribed 
traumatic  aneurysm.  A  diffused  traumatic  aneurysm  is  more  frequent 
in  the  axilla  or  groin,  where  the  tissues  are  more  readily  separated 
by  the  extravasated  blood;  the  blood  in  such  cases  is  more  apt  to 
become  clotted,  and  may  very  seriously  compromise  the  circulation 
of  the  limb.  The  semi-clotted  mass  should  be  evacuated,  and  the 
ruptured  vessels  ligated.  Fig.  189  shows  gangrene  following  ligation 
of  both  ends  of  a  ruptured  femoral  artery  and  vein,  due  to  contusion 
by  a  heavy  steel  plate,  and  accompanied  by  the  formation  of  an 
immense  diffuse  traumatic  aneurysm. 

Open  Wounds  of  Bloodvessels. — These  may  be  incised,  punctured, 
etc.,  or  due  to  gunshot  injury.  If  smaller  vessels  have  not  been 
divided  completely  by  the  original  injury,  the  surgeon  should  cut 


234 


SURGERY  OF  THE  HLOOI)    VAHCVLAR  SYSTEM 


them  entirely  across,  and  ligate  both  ends.  For  punctured  wounds 
of  the  hirijer  veins  a  lateral  lifjature  should  be  aj)plied  (Fif^.  11)0); 
by  brin_(,niin  intima  into  contact  with  intinia,  firm  union  without 
thrombosis  may  be  expected.  If  a  large  vessel,  artery  or  vein,  presents 
an  incised  wound,  and  obliteration  of  the  circulation  by  ligature  is 
likely  to  result  in  gangrene  (as  is  especially  the  case  in  the  popliteal, 
femoral,  and  axillary  arteries),  attempt  should  be  made  to  suture 
the  wound  in  such  a  way  as  to  evert  its  edges,  thus  apposing  serous 


Fig.  190. — Application  of  a 
lateral  ligature  for  puncturecl 
wound  of  vein. 


Fig.  191. — Circular  arteriorrhaphy  by  Carrel's 
method:  when  the  three  stay  sutures  are  pulled  taut, 
the  introduction  of  the  sutures  is  much  facilitated. 


surfaces.  Should  such  a  vessel,  especially  an  artery,  be  completely 
divided,  circular  arteriorrhaphy  should  be  done  fFig.  191),  using  a  very 
fine  round-pointed  needle  and  No.  500  silk,  soaked  in  sterile  vaselin 
(Carrel,  1902).  The  circulation  is  controlled  by  Crile's  clamps  (Fig. 192), 
applied  directly  to  the  wounded  vessel.  Even  if  thrombosis  follows 
the  attempt,  occlusion  of  the  artery  will  be  so  gradual  that  gangrene 
will  be  much  less  apt  to  ensue  than  after  ligation.    Should  ligation 


Fig.  192. — Crile's  clamp  for  temporary  occlusion  of  bloodvessels,  blades 
covered  with  rubber. 


of  the  main  vein  of  a  limb  be  necessary,  the  main  artery  should  not 
be  ligated  also;  to  do  so  increases  the  risk  of  gangrene.  According 
to  Wolff's  statistics  (1908),  gangrene  occurred  in  34  per  cent,  of  cases 
where  both  femoral  artery  and  vein  were  ligated,  and  in  only  8  per 
cent,  where  the  femoral  vein  alone  was  ligated.  Gumhot  and  other 
contused  wounds  rarely  admit  of  suture. 

Entrance  of  air  into   veins  is  no   longer   regarded    as    a    frightful 
calamity,  presaging  immediate  death.     In  operating  at  the  root  of 


M'or.\7).s'  OF  iiLnnn\p:ssELs 


LM.) 


the  neck,  wIktc  lu'j^ativr  pressure  in  tlie  \'eiiis  (liiriii<!;  iiisjjiratioii  is 
most  iimrked,  air  may  l)e  sucked  into  the  circulation,  and  when  in 
hirge  f|uantity  has,  in  a  few  instances,  Keen  prochictive  of  serious 
conse(|nenees.  A  suckinu',  lap])in<,',  or  ic'iruhnt;  sound  is  heard,  eh)seiy 
folh)\\ini;  a  •;usli  of  hlood  from  the  wounded  vein,  and  sometimes 
foHowed  l)y  the  apj)earanee  of  frothy  l)Io()d  in  the  wound.'  Pale- 
ness and  Hvidity,  faihire  of  the  cireuhition  and  colhipse  may  ensue. 
In  a  patient  uuik'r  my  own  care  (19()S),  in  Dr.  Frazier's  serviee  at 
the  Kpisco])al  Hospital,  no  symptoms  wliatever  were  produced, 
tliouijli  tlie  sucking  sound  of  air  entering  the  vein  (branch  eh)se  to 
subclavian)  was  very  pronouneed.  In  operations  in  the  "danger 
zone"  the  surgeon  if  ])ossible  should  apply  a  compress  to  the  region 
where  the  internal  jugular  and  subcUnian  veins  unite,  thus  causing 
back  pressure  on  the  main  trunks  above;  this  facilitates  dissection. 
When  the  accident  occurs,  plug  the  opening  with  the  finger  until 
otiier  means  of  arresting  the  hemorrhage  can  be  applied. 


Fig.  193. — Aneurysmal  vaiix  (or  direct 
arterio-venous  fistula). 


Fig.  194. — Varicose  aneurysm  (or  indirect 
arterio-venous  fistula). 


Arterio-venous  wounds  occasionally  occur  from  puncture,  stab, 
or  gunshot  injury  involving  both  artery  and  vein.  The  superficial 
parts  may  heal,  leaving  a  form  of  traumatic  arterio-venous  aneurysm: 
if  the  artery  and  vein  are  in  direct  communication,  the  condition 
is  known  as  aneurysmal  vari.r  (Fig.  193);  if  a  sac  intervenes,  it  is  a 
varicose  aneurysm  (Fig.  194).-  The  diagnosis  in  either  case  depends 
on  the  history  of  injury,  and  the  rather  tardy  development  of  signs 
of  a  traumatic  aneurysm,  accompanied  by  a  susurrus,  or  purring 
thrill,  and  in  the  case  of  a  varicose  aneurysm  by  a  distinct  impulse 
and  aneurysmal  whirr.  The  buzzing  is  continuous,  not  disappear- 
ing entirely  during  diastole  (except  sometimes  when  the  limb  is 
elevated  —  Xelaton),  but  being  accentuated  during  systole;  the 
murmur  is  transmitted   centrifugally,   sometimes  centripetally,   and 


^  A  .somewhat  similar  .sound,  but  no  bleeding,  follow.s  injury  of  the  pleura. 
-The  terminology  of  John  B.  Roberts  {arterio-venuus  fistula,  director  indirect)  is 
preferable. 


236  SURGERY  OF  THE  BLOOD   VASCULAR  SYSTEM 

the  superficial  veins  may  pulsate  (Matas).  An  aneurysmal  varix 
rarely  gives  much  distress,  except  for  the  buzzing  sensation  on  palpa- 
tion; this  may  be  audible  to  the  patient;  but  the  tumor  seldom 
enlarges,  and,  as  a  rule,  only  palliative  treatment  is  required.  If 
necessary,  however,  the  surgeon  may  attempt  separation  of  the 
vessels  and  suture  or  ligation  of  the  defects.  A  varicose  aneurysm, 
on  the  other  hand,  is  prone  to  grow  larger  progressively,  and,  though 
rarely  reaching  very  large  size,  in  many  respects  resembles  an  ordinary 
aneurysm.  Operation  generally  is  indicated;  this  may  consist 'merely 
in  ligation  of  the  more  accessible  vessel  (preferably  the  artery)  above 
and  below  the  sac,  or  in  extirpation  of  the  sac  and  suture  of  the  venous 
and  arterial  orifices;  better  still  (Bickham,  1904),  would  be  oblitera- 
tion of  the  sac  by  endoaneurysmorrhaphy  (p.  257).  For  the  success 
of  most  of  these  methods,  preliminary  control  of  the  circulation  is 
necessary;  where  this  is  impossible  the  surgeon  must  open  the  sac, 
plug  the  arterial  orifice  with  his  finger,  and  apply  a  suture  to  occlude 
the  orifice  as  quickly  as  possible;  the  venous  opening  is  next  closed. 

Injuries  of  the  Heart. — Rupture. — Rupture  of  the  heart  may  be  due 
to  injury  or  disease.  Blood  is  pumped  into  the  pericardium,  causing 
embarrassment  of  cardiac  action,  with  dyspnea,  cyanosis,  collapse, 
and  death,  before  suture  of  the  rent,  which  is  indicated,  can  be 
attempted. 

Wounds. — Wounds  of  the  heart  are  usually  stab  or  gunshot  wounds. 
In  cases  coming  to  operation,  the  left  ventricle  is  most  often  wounded, 
generally  on  the  left  of  the  sternum.  The  symptoms  are  much  the 
same  as  those  of  rupture  of  the  heart,  though  somewhat  less  severe; 
if  the  patient  does  not  die  within  a  few  minutes,  he  usually  survives 
several  hours,  aftording  opportunity  for  rational  treatment.  Wounds 
of  the  pleura  (40  to  70  per  cent.)  and  of  the  lung  (30  to  50  per  cent.), 
may  coexist,  and  pericardial  hemorrhage  may  come  from  this  source, 
and  not  from  a  wound  of  the  heart  itself.  In  all  cases  in  which 
cardiac  injury  is  suspected,  however,  exploratory  pericardiotomy 
should  be  done.  Where  no  precordial  wound  exists,  Matas  advises 
an  oblique  incision,  from  the  mid  sternum  opposite  the  fourth  inter- 
space, downward  and  toward  the  left,  dividing  the  fifth  or  sixth 
costal  cartilage,  which  is  excised.  When  an  external  wound  makes 
the  diagnosis  more  certain,  Spangaro's  incision  (19()())  in  the  fourth 
intercostal  space  is  preferable;  this  extends  from  the  left  margin  of 
the  sternum  out  as  far  as  necessary,  the  pleura  being  opened  if  already 
wounded.  If  sufficient  exposure  is  not  obtained  by  forcible  retraction 
of  the  ribs,  the  costal  cartilages  abo\'e  and  below  may  be  di^'ided 
close  to  the  sternum.  The  pericardium  being  opened  and  clots 
evacuated,  the  slippery  heart  is  grasped  in  the  left  hand,  and  the 
wound  sutured  with  a  continuous  chromic  gut  suture,  hemorrhage 
being  intermittently  controlled  by  pressure  on  the  vense  cavte  at 
their  entrance  into  the  right  auricle  (Rehn,  1907).  Usually  the 
pericardium  should  be  drained  for  twenty-four  hours,  and  the  pleura 
also,  if  invaded,  but  through  a  separate  incision.    Simon  has  collected 


TlUiOMIiOSIS   AND   KM  HOI. ISM  237 

(up  to  1912)  2n  ()])(Tati()ns  for  ^nmsliot  wounds,  with  124  doaths 
(51  por  cent.  nu)rtality);  and  2()()  operations  for  stab  wounds,  with 
99  deaths  (49  per  cent.). 

Foreign  Bodies.  Forei<2;n  bodies  in  the  heart  have  been  recorded 
in  lis  cases  (Zcsas,  1910).  Most  have  been  jxjrtions  of  needles 
or  encysted  bullets.  The  (Ha^nosis  and  localization  arc  aided  by 
radioj^raphy ;  and  extraction  by  cardiotomy  is  indicated  if  any 
.syni])tonis  are  present. 

Cardiolysis  is  an  operation  pr()i)()sed  l)y  Brauer  (1902),  and  enii)l()yc(l 
by  Petersen,  Simon,  Morison,  and  others,  consisting  in  excision  of 
portions  of  the  fifth  and  sixth  left  ribs  to  allow  more  room  for  expan- 
sion of  a  heart  hypertrophied  from  aortic  disease;  much  impro\-ement 
in  sym})toms  is  said  to  have  resulted.  Ilaberer  (1910)  employed 
a  similar  operation  for  chronic  adhesive  j)ericarditis;  while  others 
have  gone  further,  opening  the  pericardium  and  freeing  its  adhesions. 
Leriche  and  Cotte  (1909)  refer  to  IS  operations  of  the  latter  type, 
with  marked  improvement  in  all  cases. 

Pericardiotomy  may  be  required  for  serous  or  purulent  effusion 
in  the  ])ericardium.  A  trocar  may  l)e  introduced  close  to  the  stermim 
in  the  fourth,  fifth,  or  sixth  left  interspace,  according  to  the  physical 
signs,  or,  which  is  preferred  by  Matas,  at  the  left  side  of  the  base 
of  the  ensiform.  In  most  cases  it  is  better  to  make  a  formal  incision, 
dividing  the  sixth  and  seventh  left  costal  cartilages  close  to  the 
sternum.  The  latest  series  of  22  cases  of  pericardiotomy  gives  a 
mortality  of  82  per  cent.  (Elliott,  1909). 

Massage  of  the  heart,  mentioned  at  p.  175  as  useful  in  shock, 
has  been  employed,  according  to  Jurasz  (1911);  in  64  cases,  with  13 
permanent  and  15  temporary  recoveries.  Two  patients  under  m}^ 
own  care  rallied  only  for  a  few  hours. 

DISEASES  OF  THE  BLOOD  VASCULAR  SYSTEM. 

Thrombosis  and  Embolism. — When  blood  coagulates  within  the 
vessels  during  life,  the  process  is  called  thrombosis,  and  the  resulting 
clot  a  thrombus.  It  is  recognized  clinically  that  there  may  be  an 
aseptic  as  well  as  a  septic  thrombosis,  though  the  former  becomes 
rarer  the  more  we  learn  of  the  subject.  Infection  may  reach  the 
region  of  thrombosis  through  the  blood-stream,  or  by  contiguity 
from  neighboring  parts;  in  the  latter  case  it  is  customary  to  incrimi- 
nate the  perivascular  lymphatics  and  the  vasa  vasorum  as  the  avenue 
of  approach.  Accepting,  then,  infection  as  the  exciting  cause  of 
thrombosis,  we  admit  as  predisposing  causes  anything  which  slows  the 
blood-stream ,  which  produces  changes  in  the  vessel  walls,  or  in  the  com- 
position of  the  circulating  blood.  The  most  important  of  these  three 
doubtless  is  changes  in  the  vessel  walls;  and  these  changes  in  most 
instances  are  due  to  bacteria  or  their  toxins.  Aseptic  injury  seldom 
is  a  cause  of-  thrombosis  (p.  229).  Moreover,  changes  in  the  vessel 
walls,   as  in  atheroma,  phlebectasis,   etc.,   also  act  by  obstructing 


238  SURGERY  OF  THE  BLOOD   VASfTLAR  SYSTEM 

the  blood-current;  and- when  the  composition  of  the  blood  is  altered 
by  disease  {e.  g.,  infections  such  as  typhoid  fever,  appendicitis,  sup- 
purative inflammations;  metabolic  poisons,  as  in  eclampsia,  after 
burns,  etc.),  or  by  injury  (as  after  profuse  hemorrhages),  very  slight 
retardation  may  be  sufficient  to  cause  thrombosis.  The  thrombus 
formed  of  circulating  blood,  within  the  vessels,  is  either  of  the  white 
or  mixed  variety:  that  is,  it  contains  relatively  few  erythrocytes, 
as  these  flow  in  the  axial  blood-stream  furthest  from  the  vessel  walls 
where  thrombosis  is  inaugurated  by  depositon  of  blood-platelets, 
destruction  of  leukocytes,  and  formation  of  fibrin  ferment.  The 
thrombus  thus  formed  may  be  a  parietal  thrombus  only,  not  occlud- 
ing the  entire  vascular  lumen,  or  it  may  be  a  complete  or  obstructing 
thrombus.  In  either  case  portions  may  be  broken  off  by  external 
injury  or  simply  by  force  of  the  circulation;  and  such  an  embolus, 
being  carried  away  in  the  blood-stream,  may,  when  it  is  arrested 
(embolism),  produce  a  secondary  thrombus,  so  named  in  contradistinc- 
tion to  the  original  primary  thrombus.  The  thrombus,  whether  primary 
or  secondary,  undergoes  in  time  certain  changes  analogous  to  organiza- 
tion, cicatrization,  and  contraction,  as  studied  in  Chapter  I;  by  these 
processes  the  vessel  affected  becomes  converted  into  a  solid  fibrous 
cord  of  connective  tissue.  Occasionally'  small  parietal  thrombi  are 
absorbed:  rarely  obstructing  thrombi  become  canalized  by  the  gradual 
development  in  them  of  capillaries  which  subsequently  dilate  and 
re-establish  permeability  for  the  blood-stream;  not  seldom  infective 
thrombi  disintegrate  by  suppuration,  and  then  the  emboli  derived  from 
such  a  thrombus  may  cause  metastatic  abscesses  (p.  73).  Finally, 
throml)i  may  become  calcified,  especially  in  veins,  where  they  are 
converted  into  phleboliths. 

Phlebitis. — Phlebitis,  or  inflammation  of  a  vein,  is  due  in  general 
to  the  same  factors  mentioned  above  as  causing  thrombosis;  and, 
as  may  readily  be  understood  from  what  was  there  said,  thrombosis 
is  a  much  more  frequent  occurrence  in  veins  than  in  arteries,  ^'enous 
blood  normally  clots  more  quickly  than  arterial;  the  normal  venous 
current  is  slow,  is  opposed  by  the  force  of  gravity  and  by  the  valves 
in  the  veins;  the  veins  are  superficial,  not  supported  by  the  muscles, 
and  thus  liable  to  trauma  and  to  extension  of  infection  from  the 
skin  and  its  lesions;  and  their  walls  are  thin,  and  liable  to  be  varicose, 
thus  forming  pouches  where  the  blood  eddies  and  stagnates.  In 
spite  of  all  these  factors  which  predispose  to  primary  thrombosis, 
it  is  not  impossible  for  phlebitis  to  exist,  at  least  for  a  time,  without 
thrombus  formation.  Thus  in  many  cases  of  varicose  veins  (p.  242) 
there  is  chronic  phlebitis  (phlebosclerosis),  with  marked  thickening 
of  the  venous  walls,  yet  without  thrombosis.  Such  cases  probably 
are  due  to  the  action  of  metabolic  poisons,  not  to  septic  infection, 
unless  this  is  extremely  attenuated.  Surgeons  thus  distinguish 
clinically  between  plastic  and  infective  or  .septic  phlebitis,  the  latter 
being  accompanied  in  practically  all  cases  by  throml)osis,  and  running 
a  much  more  acute  course. 


TlinOMBOSlS   AM)   KM  HOLISM 


289 


Tlu"  tliroinbus  wliicli  forms  in  a  \('iM  as  a  rule  cxtciids  rather  raj)i(lly 
ill  the  direction  ot"  the  hlood-current,  inxadinji;  not  int're(|ueiitly  the 
nearest  brandies  in  the  tiironihotic  process;  tlie  clot  extends  also  hut 
to  a  less  deforce  on  the  distal  side  of  the  obstruction.  Thus  throm- 
bosis be^imiiuf;  in  the  lonff  saphenous  vein  Ix'hind  the  internal  malleo- 
lus, or  in  the  lower  le^,  may  extend  to  the  femoral;  and  from  this 
the  iliac  \eins  and  even  the  vena  ca\a  may  become  thrombosed. 
Tiirombosis  commencing  in  the  appendicular  veins  may  extend  to 
the  portal  vein  and  into  the  liver.  Thrombosis  commencing  in  the 
facial  or  angular  vein  may  extend  to  the  cerel)ral  sinuses;  and  throm- 
bosis conunencing  in  the  lateral  sinus  fre(|uently  extends  into  the 
internal  jugular  vein. 

Symptoms. — These  are  the  usual  symj)ton)s  of  inflammation,  more 
or  less  localized  to  the  known  course  of  a  \"ein.  Pain  fre(]uently 
is  the  first  symptom  to  attract 
attention;  examination  soon  after 
discloses  Jieat,  a  dusky  redness  in 
the  line  of  the  veins ;  and  often  the 
thickened,  tender,  cord-like  vein 
can  be  palpated  through  the  over- 
lying tissues.  Great  gentleness 
must  be  used  in  examination,  for 
fear  of  detaching  an  embolus. 
Sometimes  the  position  of  the 
valves  can  be  recognized  by  the 
presence  of  knobby  protuberances, 
^"ery  rarel>'  suppuration  occurs, 
multiple  abscesses  forming  along 
the  course  of  the  vein.  There  is 
moderate  swell ing  from  the  first, 
and  if  thrombosis  is  complete, 
and  especially  if  a  main  trunk 
is  involved,  there  is  a  certain 
amount  of  edema  in  the  parts 
beyond.  In  advanced  cases  there 
is  total  disability  of  the  affected 
extremity.  The  disease  lasts  from 
one  to  three  or  four  weeks.  Per- 
manent occlusion  of  the  affected 
veins  results  in  compensatory 
dilatation  of  collaterals,  whicli 
may  themselves  be  the  cause  of  annoyance  or  (lisa})ility  (Fig.  195). 

Diagnosis. — Predisposing  causes  must  be  considered  (infections, 
injury),  and  the  physical  signs  mu.st  be  accurately  noted.  By  the 
latter  means  phlebitis  may  l)e  distinguished  from  (1)  Lj/nijjhangelfis 
(p.  2()<S),  where  the  redness  is  more  fiame  colored,  where  the  inffam- 
mation  seems  more  superficial,  where  it  does  not  follow  the  known 
course  of  a  vein,  where  a  thickened  knobby  cord  cannot  be  palpated, 


Fig.  19.5. — Eijisiastrio  \'arioositips  fol- 
lowing typhoid  thrombosis  of  iliac  veins. 
Episfopal  Hospital. 


240  SURGERY  OF  THE  BLOOD   VASCULAR  SYSTEM 

and  where  lymphadenitis  is  a  frequent  accompaniment;  from  (2) 
Periostcitis  and  Ofiieomyelitis,  where  the  superficial  veins  are  not 
affected,  where  tenderness  and  pain  are  limited  to  the  bone  affected, 
not  extending  past  the  nearest  joint;  where  history  of  direct  trauma 
is  frequent;  and  where  tapping  the  suspected  bone  almost  at  any 
part  of  its  shaft  is  productive  of  pain  at  the  seat  of  greatest  disease; 
and  from  (3)  Neuralgia  and  Neuritis,  where  the  symptoms  are 
localized  to  the  known  course  of  a  ner^•e,  and  where  no  physical 
signs  of  inflammation  are  present. 

Post-operative  Phlebitis  has  laparotomy  as  its  most  frequent  cause, 
and  usually  affects  the  veins  of  the  left  lower  extremity.  It  not 
infrequently  occurs  after  apparently  aseptic  operations,  and  it  runs 
a  comparatively  mild  course.  Clark  (1902)  attributed  it  to  injury 
of  the  deep  epigastric  vein  by  the  retractors  used  in  abdominal 
section. 

Phlegma.sia  Alba  Dolens  is  a  term  used  to  describe  inflammation 
of  the  veins  and  lymphatics,  usually  of  the  left  lower  extremity, 
and  generally  due  to  puerperal  sepsis  ("milk  leg").  The  usual  signs 
of  phlebitis  are  present,  but  the  disease  is  characterized  especially  by 
the  marked  edema,  rendering  the  skin  tense  and  shiny,  probably  due 
to  coincident  diffuse  angeioleucitis ;  and  by  the  pallor  of  the  affected 
extremity. 

Treatment. — Phlebitis  is  a  serious  disease,  and  requires  efficient 
treatment.  Local  rest,  which  usually  implies  confinement  to  bed, 
and  elevation  of  the  limb,  should  be  insisted  on.  Gentle  support, 
as  by  flannel  bandages,  aids  elevation  in  preventing  excessive  edema. 
Local  applications  have  little  appreciable  effect,  but  the  use  of  ice 
bags  in  the  early  stages,  and  of  heat  later,  usually  is  grateful  to  the 
patient.  Ichthyol  or  mercury  and  belladonna  ointment  may  be 
applied  to  the  seat  of  greatest  inflammation.  The  skin  should  be 
kept  clean,  and  well  dried,  by  washing  gently  with  alcohol  once  every 
other  day  or  so;  but  under  no  circumstances  should  massage  be 
attempted,  and  none  but  the  very  gentlest  passive  movement  of  the 
extremity  should  be  allowed.  Absolute  rest  of  the  afl'ected  part 
should  be  maintained  for  at  least  one  week  after  all  symptoms  hare 
subsided.  If  the  leg  is  affected  there  will  be  persistent  edema  for 
many  weeks  or  months  after  the  patient  gets  about,  and  an  elastic 
stocking  or  firm  bandaging  will  be  necessary  to  promote  ease  in 
locomotion.    General  treatment  is  the  same  as  in  any  acute  infection. 

The  treatment  above  described  is  sufficient  in  the  immense  majority 
of  cases  of  plastic  phlebitis;  but  in  some  cases  of  septic  phlebitis  it  is 
proper  to  attempt  to  prevent  the  further  spread  of  the  thrombotic 
process  by  excising  a  portion  of  the  main  venous  trunk  some  distance 
on  the  cardiac  side  of  the  furthest  limits  of  inflammation.  Thus  for 
thrombosis  extending  up  the  long  saphenous  vein,  this  trunk  may  be 
doubly  ligated  and  a  section  excised  (Fig.  196),  or  the  vein  simply 
divided,  at  the  saphenous  opening.  In  thrombosis  of  the  lateral 
sinus,  following  otitis  media,  it  is  the  rule  to  divide  the  internal 


THROMBOSIS  AM)  EMIiOLlS.U 


241 


juj;iilar,  wIutc  licaltliy,  between  two  ligatures;  and  some  surgeons 
advise  ligating  all  hranohes  and  excising  as  much  as  possible  of  the 
tlironil)()S(>d  venous  channels.  In  septic  thrombosis  of  the  oxarian 
veins,  following  ])uer])eral  metritis,  many  surgeons  ha\e  attempted  to 
prevent  propagation  of  the  thrombus  by  ligation  above  the  limit  of 
disease  (('hai)ter  XXIX).  The  operation  of  phlebotomy,  with  extrac- 
tion of  the  dot  and  suture  of  the  vein  is 
not  so  ])romising  as  arteriotomy  for 
arterial  eml)olism  (p.  242),  as  the 
intima  of  the  thrombosed  vein  is  so 
diseased  as  almost  necessarily  to  ensure 
recurrence  of  thrombosis;  nor  is  the 
operation  so  desirable,  since  gangrene 
is  less  to  be  feared  than  from  arterial 
occlusion.  Wolff  (1908)  showed  that 
in  the  lower  extremity  operative  occlu- 
sion of  the  main  arteries  (137  cases) 
caused  gangrene  in  20  per  cent,  of 
cases;  while  occlusion  of  the  femoral 
vein  alone  (31)  cases)  resulted  in  gan- 
grene in  less  than  G  per  cent.  In  the 
upper  extremity  arterial  occlusion  (153 
cases)  caused  gangrene  in  about  8  per 
cent.;  only  one  case  of  ligation  of  the 
(axillary)  vein  was  recorded,  which  did 
not  result  in  gangrene. 

Pulmonary  Embolism.  —  Pulmonary 
embolism,  sometimes  an  alarming  con- 
sequence of  venous  thrombosis,  and 
often  occurring  at  the  onset  of  post- 
operative convalescence,  has  been  considered  at  p.  178.  Other  forms 
of  venous  embolism,  affecting  the  viscera  (especially  the  liver),  are  of 
comparatively  little  surgical  interest,  except  when  occurring  in  pyemia. 

Arteritis. — Arteritis  requiring  surgical  treatment  is  a  much  rarer 
condition  than  phlebitis.  In  chronic  arteriosclerosis,  with  threatening 
or  even  developed  gangrene  (so-called  senile  or  presenile  gangrene), 
reversal  of  the  circulation,  as  suggested  by  Carrel  and  Guthrie,  has 
been  attempted,  by  anastomosing  the  femoral  artery  and  vein;  the 
theor\'  being  that  the  veins,  their  valves  being  incompetent,  ofTer 
less  peripheral  resistance  to  the  outflowing  blood-current  than  the 
sclerotic  arteries.  Though  the  operation  appears  to  have  been  under- 
taken in  about  (53  cases  (Zesas,  1912),  there  was  cure  or  improvement 
in  only  8  instances;  whether  such  results  justify  the  hazard  of  the 
primary  operation  must  be  determined  for  each  case  individually. 
(See  Senile  Gangrene,  p.  61.) 

Arterial  Thrombosis. — Arterial  thrombosis  occurs  as  a  complication 
of  wounds,  compound  fractures,  cellulitis,  etc.;  but  unless  affecting 
the  main  artery  of  a  limb,  which  is  rare,  its  symptoms  usually  are 
16  ' 


Fig.  V.HJ. — Portion  of  thronibosod 
internal  saphenous  vein,  excised  at 
its  juncture  with  the  femoral. 
Episcopal  Hospital. 


242  SURGERY  OF  THE  BLOOD   VASCULAR  SYSTEM 

overshadowed  by  those  of  the  causative  condition.  When  the  main 
artery  of  a  limb  is  affected,  the  symptoms  differ  only  in  the  less  sudden 
onset  from  those  of  arterial  embolism,  presently  to  be  described. 
F.  T.  Stewart  (1908)  refers  to  35  cases  of  traumatic  arterial  thrombosis, 
31  of  which  terminated  in  gangrene.  The  treatment  is  the  same  as 
for  embolism. 

Arterial  Embolism. — Arterial  embolism,  when  affecting  the  main 
artery  of  a  limb,  is  a  condition  of  great  gravity.  The  clot  usually 
is  derived  from  one  of  the  cardiac  valves;  it  is  detached  from  no 
apparent  exciting  cause,  is  carried  away  in  the  blood-stream,  and  if 
lodging  so  as  to  ])lug  an  artery  of  considerable  size,  presents  charac- 
teristic and  well  marked  symptoms.  The  patient  suffers  a  sudden, 
acute,  stinging  pain  below  the  site  of  embolism,  in  the  distribution 
of  the  affected  artery;  the  limb  below  becomes  tingling,  numb,  or 
for  a  time  the  seat  of  burning  pain;  pulsation  is  absent  below  the 
site  of  embolism;  and  the  limb  gradually  grows  cold,  bluish,  livid, 
and  the  signs  of  oncoming  gangrene  appear  (p.  60).  Fig.  20  (p.  62) 
shows  gangrene  due  to  lodgement  three  weeks  previously  of  an  embolus 
in  the  popliteal  artery,  in  a  patient  who  three  months  before  had 
embolism  of  a  cerebral  artery. 

Treatment. — When  the  embolus  lodges  in  an  accessible  situation, 
and  in  one  where  sudden  complete  arterial  occlusion  habitually 
results  in  gangrene  (especially  the  brachial  at  the  elbow,  the  femoral 
and  popliteal  arteries),  the  surgeon  should  lose  no  time  in  resorting 
to  arteriotomy  and  extraction  of  the  clot  (F.  T.  Stewart,  1908). 
This  is  a  more  promising  procedure  for  embolism  with  secondary' 
thrombosis,  than  for  primary  thrombosis,  since  the  healthier  con- 
dition of  the  arterial  coats  in  the  former  condition  makes  recurrence 
of  thrombosis  less  likely.  According  to  Le  Conte  and  Stewart  (1910) 
arteriotomy  for  thrombosis  or  embolism  has  been  done  in  7  cases; 
at  least  3  of  the  patients  died,  and  in  none  was  gangrene  prevented. 
Since  the  publication  of  these  statistics  one  successful  case  of  arteri- 
otomy for  femoral  embolism  (aseptic)  has  been  reported  by  Mosny 
and  bumont  (1911). 

Varix,  Phlebectasis,  or  Varicose  Veins,  describes  a  condition  in 
which  the  veins  become  elongated,  dilated,  tortuous,  and  pouched.  Any 
veins  may  be  affected,  even  those  of  bone;  but  superficial  veins, 
especially  the  ^'eins  of  the  spermatic  cord  and  the  saphenous  ^'eins 
of  the  lower  extremities,  are  most  noticeably  diseased  (Fig.  197). 
The  chief  cause  is  gravitation,  aided  by  obstruction  to  the  normal 
venous  current.  Occupation  (barbers,  waiters,  motormen,  or  others 
who  stand  for  hours  at  a  time),  tumors,  pregnancy,  thrombosis  (Fig. 
195),  or  other  factors  producing  obstruction,  are  all  predisposing 
causes.  Usually  no  one  well  defined  cause  can  be  found.  The  valves 
become  incompetent,  the  blood  stagnates,  hypertrophy  and  sclerosis 
of  the  vessel  walls  occur,  phleboliths  may  develop,  and  thrombosis 
may  finally  cause  obliteration  of  the  diseased  veins.  The  symptoms 
of  pain,  fulness,  weight,  etc.,  are  frequently  disabling;  in  the  lower 


VARICOSE   VEINS 


243 


Fig.  197. — -Varicose  internal 
saphenous  vein,  aged  sixty-three 
years ;  duration  over  forty  years. 


extremities  the  perivascular  tissues  become  thickened,  liard  edema 
develops,  the  nutrition  of  the  skin  suffers;  trifling  trauma  produces 
an  abrasion  which  fails  to  heal,  and  varicose  ulcer  results  (p.  57). 
Profuse  hemorrhage  may  occur  from 
spontaneous  rupture  of  a  varix.  Rup- 
ture of  a  deep  varicose  vein  is  attended 
by  sudden  stinging  pain  ("coup  dc 
fouet")  and  subsequent  appearance  of 
ecchymosis.  •  Treatment  may  be  pallia- 
tive or  radical.  The  former  includes 
api)lication  of  elastic  bandages  or 
stockings,  after  emptying  the  veins 
and  reducing  edema  by  elevation  of 
the  limb;  the  use  of  stimulating  lini- 
ments, etc.;  and  attention  to  hygiene. 
Such  treatment  always  should  be  tried 
first,  and  usually  is  efficient  when  the 
cause  of  the  obstruction  is  temporary 
(pregnancy),  or  removable  (tumor, 
etc.).  In  other  cases,  or  when  pallia- 
tive measures  fail  to  relieve  symptoms, 
operation  is  indicated.  If  the  super- 
ficial veins  are  varicose  as  a  result  of  thrombotic  obstruction  of  the 
deep  veins,  no  operation  should  be  attempted  unless  elastic  support 
with  temporary  obliteration  of  the  varicosities  produces  relief  and 
demonstrates  the  efficiency  of  the  collateral  circulation.  Very  occa- 
sionally varicosities  due  to  this  cause  disappear  spontaneously 
after  a  few  vears,  owing  to  the  development  of  collateral  circulation 
(Skillern,  1913). 

Operative  Treatment. — Operative  treatment  consists  in  obliteration 
of  the  varicose  channels  at  one  or  several  points.  Schede's  operation 
(1877)  is  done  by  making  a  circular  incision  below  the  knee  down  to 
the  deep  fascia,  thus  dividing  all  the  superficial  veins;  both  ends  of 
each  divided  vessel  are  then  ligated,  and  the  skin  sutured.  This 
operation  also  divides  the  superficial  lymphatics  and  sensory  nerves; 
sometimes  is  followed  by  edema,  paresthesias,  neuralgias,  or  trophic 
disturbances  in  the  skin  below;  and,  according  to  Matas,  is  followed 
by  permanent  cure  in  only  one-third  of  the  cases.  Spiral  division  of 
the  skin  enables  the  surgeon  to  obliterate  all  the  venous  channels 
without  severing  all  the-  lymphatics,  thus  rendering  edema  less 
likely;  but  section  of  the  nerves  can  scarcely  be  avoided.  Tre?i- 
delenburg's  operation  (1890)  consists  in  division  of  the  main  varicose 
trunk  (usually  the  long  saphenous  above  the  knee)  between  two 
ligatures,  the  object  being  to  break  the  column  of  blood,  thus  relieving 
pressure  symptoms.  It  is  suitable  for  those  cases  where  only  the 
main  trunk,  not  its  collaterals,  is  varicose;  and  is  not  suitable  even 
for  those  cases  if  the  saphenous  vein  is  the  seat  of  chronic  phlebitis. 
According  to  Matas,  79  per  cent,  of  patients  treated  by  Trendelen- 


244  SURGERY  OF  THE  BLOOD  VASCULAR  SYSTEM 

burg's  operation  have  been  cured  or'  greatly  improved.  Multijde 
Phlebcctomi/,  associated  with  the  names  of  Madelung  (1884)  and 
Schwartz  (1888),  is,  I  beheve,  the  best  operation  in  the  vast  majority 
of  cases.  Sections  of  the  diseased  veins,  three  or  four  inches  long, 
^are  removed  at  the  saphenous  opening  and  in  other  parts  of  the  thigh 
and  leg,  wherever  the  main  trunks  or  their  branches  are  most  dilated ; 
the  intervening  portions  become  thrombosed,  contract,  and  produce 
no  further  symptoms;  and  the  greater  portion  of  the  diseased  tissue 
is  completely  removed  from  the  body,  which  is  not  accomplished  by 
either  Schede's  or  Trendelenburg's  operation.  If  the  surgeon  wishes, 
he  can  remove  the  entire  saphenous  vein  through  one  long  incision; 
or  by  passing  a  curette  over  the  ligated  end  of  the  main  trunk,  as 
practised  by  C.  H.  Mayo  (1906),  and  ripping  off  its  branches  by 
subcutaneous  tunnelling  with  this  instrument,  the  entire  vein  may 
be  removed  through  three  or  four  small  incisions.  These  methods, 
though  more  spectacular  than  multiple  phlebectomy,  which  is  a 
tedious  procedure,  are  less  sure,  since  the  diseased  collaterals  are 
left  behind.  In  many  cases,  moreover,  the  veins  are  calcareous, 
and  so  densely  adherent  to  the  perivascular  tissues  and  even  to  the 
skin,  that  only  a  formal  dissection  can  free  them.  I  have  always 
employed  multiple  phlebectomy,  except  in  cases  due  to  thrombosis  of 
the  deep  veins;  in  these  I  have  adopted  a  spiral  incision  for  Schede's 
operation,  thus  avoiding  excision  of  the  only  veins  the  patient 
possessed.  Operations  for  varicose  veins  are  not  entirely  devoid  of 
danger:  in  large  series  of  operations  death  from  pulmonary  embolism 
has  occurred  in  1  or  2  per  cent,  of  cases;  the  skin  frequently  is  difficult 
to  sterilize,  and  in  spite  of  care  infection  of  the  incisions  may  occur; 
occasionally  phlebitis  is  a  sequel. 

Hemangeiomas ;  Telangiectases. — Under  these  terms  are  included 
various  affections  of  the  vascular  system,  whose  proper  classification 
has  not  been  determined  by  pathologists.  In  the  vast  majority  of 
cases  they  are  cojigenital,  or  at  least  are  noticed  first  in  early  infancy; 
the  lesions  usually  enlarge  more  rapidly  than  the  part  in  which  they 
are  situated,  and  from  being  insignificant  specks  at  birth  may  become 
growths  of  alarming  size  in  childhood  or  early  adult  life.  Sometimes 
they  assume  the  character  of  tumors,  as  descril)ed  in  Chapter  IV, 
very  occasionally  seeming  to  possess  malignant  characteristics  (in- 
filtration, recurrence). 

Nevus  Vasculosus. — This  may  affect  either  capillaries  or  venules, 
its  color  (bluish,  purplish,  or  red)  depending  upon  the  proportion  of 
venous  blood  present. 

Capillary  Nevi  (Plate  II,  Fig.  1). — Capillary  nevi  occur  in  the  skin, 
rarely  in  mucous  membranes;  they  do  not  involve  the  subcutaneous 
tissues;  they  are  red,  or  reddish  blue  ("mother's  mark,"  "birth-mark," 
"port-wine  stain");  they  may  be  elevated  above  the  surface  of  the 
surrounding  skin,  or  may  lie  perfectly  flat  beneath  a  seemingly  normal 
epiderm.  They  vary  greatly  in  size.  Elevation  of  the  affected  part 
does  not  cause  them  to  shrink  or  become  pale;  nor  does  pressure 


HEMANGEIOMA    AND  NEVUS 


245 


blaiuli  tlii'iii,  unless  very  small,  and  then  only  momentarily.  Tsually 
they  are  nuilti])le,  are  most  frecjuent  on  the  face  and  neck  (])erhaps 
branchi()«;('nic) ;  tend  to  ji^row  lar<i;er;  and  may  ulcerate  and  cause 
alarming  liemorrhage.  Sometimes  they  blend  into  caccrnous  angeio- 
mas,  described  below.  The  pigmented  mole  may  be  considered  a 
\ariety  of  capillary  nevus:  fre- 
((uently  it  is  hairy  (netu.'i  /j/Zoa'?/*, 
Fig.  MIS);  usually  remains  of  in- 
significant size;  but  occasionally 
about  puberty,  or  in  adult  life, 
from  trifling  of  no  apparent  cause, 
begins  to  enlarge,  assumes  tumor- 
like  characteristics,  and  may  de- 
velop into  or  be  inexplical)ly  asso- 
ciatetl  with  melanotic  sarcoma  (p. 
129). 

Treatment. — The  treatment  of 
capillary  nevi  should  be  under- 
taken within  the  first  few  months 
of  life.  The  application  of  carbon 
dioxide  snow  (Pusey,  1907),  for  a 
half  minute  or  so,  every  three  or 
four  days,  probably  is  the  most 
satisfactory  treatment  for  the  port- 
wine  stains  or  other  nevi  not  raised  above  the  surface  of  the  sur- 
rounding skin.  This  "cold  caustic,"  as  it  has  been  called,  produces 
sloughing  of  the  diseased  skin,  resulting  in  an  ulcer  which  heals  with 
the  minimal  amount  of  scarring.  The  earlier  the  nevus  is  cured,  the 
more  inconspicuous  will  the  scar  be.  Fuming  nitric  acid  is  more 
effectual  for  raised  capillary  nevi  than  for  port-wine  stains.  Elec- 
trolysis may  also    be    em- 


Fk;.  lOS.-  -.\c\us  pilnsiis  I  luiiry  mole). 
Age  nineteen  years,  growing  slowly 
since  birth.     Episcopal  Hospital. 


ployed.      Moles    are    best 
treated  by  excision. 

Venous  Nevi.  —  ^'enous 
nevi  may  occur  in  the  skin 
or  subcutaneously,  in  the 
latter  case  usually  being  de- 
scribed as  cavernous  angeio- 
mas,  their  structure  resem- 
bling the  cavernous  tissues 
of  the  penis.  They  form 
prominent  lobulated tumors, 
easily  compressible,  some- 
times becoming  tense  when  the  child  cries  or  strains,  emptying  more 
or  less  completely  when  the  affected  part  is  elevated  and  pressure  is 
applied,  and  rapidly  refilling  when  the  part  is  dependent  (Figs.  199, 
200).  In  the  subcutaneous  variety  discoloration  of  the  skin  may  not  be 
present.  The  growths  may  be  circumscribed  or  diffuse ;  the  former  some- 


FiG.  199. — Cavernous  angeioma  of  palm,  hand 
dependent.  From  a  patient  under  Dr.  Frazier's 
care  in  the  Episcopal  Hospital. 


246 


SURGERY  OF  THE  BLOOD   VASCULAR  SYSTEM 


times  is  mistaken  for  a  cold  al)scess;  while  the  diffuse  su})Cutaneous 
cavernous  angeioma  may  involve  an  entire  extremit}^  and  neighl)oring 

portions  of  the  trunk,  the  en- 
tire limb  being  deformed, 
flabby,  pudgy,  and  sponge-like 
to  the  touch  (pseudo-elephan- 
tiasis); the  muscles  may  be 
wasted,  and  the  bones  atro- 
phic (Plate  III) .  Muscle  tissue 
itself  may  be  invaded  by  the 
angeiomatous  growth.  Similar 
angeiomas  occasionally  are 
found  in  the  viscera,  notably 
the  liver.  Subcutaneous  caver- 
nous angeiomas  usually  are 
associated  with  lipomatous 
growths  {newid  lipoma).  They  seldom  cause  hemorrhage  but  may 
undergo  thrombosis;  and  formation  of  phleboliths  is  not  uncommon. 
Treatment. — Treatment  consists  in  excision  whenever  this  is 
practicable;  and  in  circumscribed  angeiomas  it  usually  is  not  very 
difficult.  If  excision  be  refused  by  the  parents,  the  surgeon  may 
strangulate  the  tumor  by  ligating  it  in  sections,  leaving  the  protruding 
masses  to  be  separated  as  sloughs.  A  round  nevus  may  be  strangulated 
by  a  double  or  quadruple  ligature  (Fig.  201 ),  while  an  elongated  growth 


Fig.  200. — Cavernous  angeioma  of  palm,  hand 
elevated.     Episcopal  Hospital. 


Fig.  201. — Strangulation  of  nevus  by  the  quadruple  ligature:   A,  the  ligature  being 
introduced;  B,  the  loops  have  been  cut  and  the  ends  of  the  ligatures  tied. 


may  be  attacked  by  Erichsen's  method  (Fig.  202).  In  cases  where 
an  elastic  tourniquet  or  other  means  of  controlling  the  circulation 
can  be  applied  above  the  seat  of  operation,  Wyeth's  method  (1903) 
may  be  adopted:  this  consists  in  the  repeated  injection  of  boiling 
water  (1  to  2  c.c),  at  intervals  of  several  days;  if  the  water  is  actually 
boiling,  thrombosis  of  the  blood  in  the  angeioma  will  be  immediate 
and  the  clot  so  firm  that  theoretically  no  fear  of  embolism  need 
occur;  but  though  no  such  result  has  been  reported,  so  far  as  I  am 


< 

Oh 


ANEl'in-S.\f 


IW 


aware,  the  siir<;('()ii  should  I)r  rxtrciiicly  cautious  in  ('ini)loyin^  this 
uu'thoil  ahout  the  lace,  where  eerehral  enihohsin  iui<i;ht  occur,  or  at 
the  root  ot"  the  neck  or  iu  the  axilhi,  where  ])uhnoii!ir\  enihohsm 
nii^ht  he  caused.  I  )iiruse  suhcutauetMis  caxcrnoiis  anji'eioiuiis  usu.illy 
can  he  tn^ited  only  hy  palliation. 


Fig.  202. — Lif^atioii  of  a  nevus  hy  Erichsen's  method:  one-half  the  thread  i.s  dyed 
l)Uick;  after  the  Usature  has  been  inserted  in  serpentine  manner  {A),  the  black  loops 
arc  cut  on  one  side  and  the  white  loops  on  the  other  side  o(  the  nevus,  and  the  black 
ends  are  ticnl  to  the  black,  the  white  to  the  white. 

Arterial  Varix. — Arterial  varix,  know^n  also  by  the  name  of  Cirsoid 
Aneurysm  (Fig.  203),  and,  when  capillaries  are  involved,  by  the  terms 
Racemose  Aneurysm  and  Aneurysm  by  Anastomosis,  is  an  affection  of 
the  arterial  system  somewhat  analogous  to  varicose  veins,  but  present- 
ing in  many  cases  neoplastic  characteristics  by  which  it  is  allied  to 
angeiomas.  The  arterial  distribution  affected  (most  frequently  on  the 
scalp)  becomes  dilated,  elongated,  tortuous,  and  imuched,  forming  a  vari- 
cose pulsating  timior  often  of  considerable  size.  It  occurs  usually  in 
early  adult  life,  from  no  well  defined  cause,  though  history  of  trauma 
may  be  obtainable,  and  cases  have  developed  from  congenital  nevi.  The 
tumor  presents  a  characteristic  varicose  appearance,  is  compressible, 
and  may  be  reduced  in  size  by  pressure  on  the  main  afferent  arterial 
trunks;  when  this  pressure  is  removed,  the  tumor  again  increases 
in  size,  by  expansile  pulsation,  perhaps  several  cardiac  impulses 
being  required  before  it  regains  full  size.  Palpation  and  auscultation 
detect  a  systolic  thrill. 

Treatment.^Treatment  is  sought  by  the  patient  for  relief  from  the 
constant  murmur  or  whirr  within  the  tumor,  as  well  as  on  account 
of  the  deformity.  Excision  should  be  done  when  practicable;  some- 
times it  becomes  possible  only  after  preliminary  circumferential 
ligation  of  the  main  arterial  channels  entering  the  tumor  (Fig.  203). 
In  rare  cases  such  ligation  alone  is  sufficient  to  cause  disappearance 
of  the  tumor. 

Aneurysm. — An  aneurysm  is  a  hollow  sac,  filled  with  normal  or 
altered  blood,  in  communication  with  the  lumen  of  an  artery,  and 
developed  wholly  or  in  part  by  progressive  dilatation  of  the  arterial 
walls.     A  traumatic  aneurysm  (p.  233)  properly  is  not  an  aneurysm 


248 


SURGERY  OF  THE  BLOOD   VASCULAR  SYSTEM 


at  all,  but  a  pulsating  hematoma,  since  the  sac  is  formed  not  of  arterial 
wall,  but  by  condensation  of  surrounding  tissues.  Arterial  aneurysms 
are  classified  as  true  and  false;  formerly  the  term  "true"  was  applied 
only  to  those  aneurysms  composed  of  all  the  arterial  coats;  but  as 
this  condition  was  found  to  exist  only  in  an  extremely  limited  number 
of  cases  of  very  minute  (miliary)  aneurysms,  it  has  now  been  trans- 
ferred to  all  aneurysms  developed  wholly  or  in  part  by  progressive 
dilatation  of  the  arterial  walls;  while  the  term  "false  aneurysm"  is 
now  applied  only  to  '  pulsating  hematomas,  etc.  When  a  true 
aneurysm  ruptures  subcutaneously  it  is  better  to  call  it  a  "ruptured 
aneurysm,"  than  a  diffused  or  consecutive  aneurysm  (Fig.  204). 


Fig.  20.3. — Cirsoid  aneurysm,  arterial  vanx, 
or  aneurysm  by  anastomosis  of  right  ear,  treated 
by  a  series  of  operations  by  the  late  Prof. 
Ashhurst:  1.  Ligation  of  temporal  and  common 
carotid  arteries.  2.  Ligation  of  growth  by  Erich- 
sen's  method  (Fig.  202).  .3.  Amputation  of  ear, 
excision  of  tumor,  and  ligation  of  cut  vessels 
separately.     University  Hospital. 


Fici.  204. — Rui)tured  aneurysm 
of  left  femoral  artery;  ligation  in 
Scarpa's  triangle  thirteen  years  ago 
for  popliteal  aneurysm.  Rupture 
two  weeks  ago.  Episcopal  Hospital. 


Aneurysm  develops  by  the  gradual  dilatation  of  a  portion  of  the 
arterial  wall  previously  diseased.  At  this  earliest  stage  the  term 
arteriectasis  is  applicable.  As  the  dilatation  proceeds,  the  middle 
tunic  gives  way,  and  the  aneurysmal  wall  is  formed  only  of  the 
adventitia  with  such  clots  as  may  be  deposited  from  the  swirling 
blood  within  the  sac  upon  the  surface  of  the  intima.  The  walls  of  an 
aneurysmal  sac  in  contact  with  circulating  blood  always  are  lined 
by  endothelial  cells,  which  are  proliferated  with  great  readiness  either 
by  extension  from  the  intima  of  the  parent  artery,  or  possibly 
through  the  medium  of  angeioblasts  of  the  vasa  vasorum  (Matas, 
1910).  This  endothelial  lining  may  itself  become  atheromatous  and 
calcareous. 


ANEURYS.U 


249 


Aneurysms  are  fiirtlier  classified  as  to  their /o/v/i,  into  (1)  Tubular 
or  Fu^siforiii  (Fiji-  -^)'>);  (-)  Saccular  (Fig.  -0(»);  and  (3)  Disscctinxj 
Aneury.s)ii.s.  Tubular  or  fusiform  aneurysms  are  those  which  involve 
the  entire  circunifereiice  of  an  artery,  and  are  rare  even  in  the  larger 


Fig.  205. — Fusiform  anour\!5ni. 


Fig.  200. — Saccular  aneurysm,  with 
small  mouth. 


internal  vessels.  Dissecting  aneurysms  are  those  in  which  the  blood 
makes  a  channel  for  itself  between  the  coats  of  the  arterial  wall  for  a 
variable  distance,  and  again  enters  the  arterial  lumen;  they  are  seen 
almost  exclusively  in  the  tho- 
racic or  abdominal  aorta.  The 
saccular  aneurysm,  in  which  the 
dilatation  involves  a  portion 
only  of  the  arterial  circumfer- 
ence, communicates  with  the 
vessel  by  a  comparatively  small 
orifice  called  the  mouth  of  the 
sac;  by  progressive  growth  of  a 
saccular  aneurysm  its  mouth 
may  become  so  lengthened  as 
to  cause  the  aneurysm  to  re- 
semble at  first  glance  one  of 
tubular  or  fusiform  variety, 
especially  on  laying  open  the 
sac,  when  it  will  appear  that 
there  are  two  mouths  present 
(Fig.  207,  B).  Though  aneu- 
rysms usually  are  single,  they 

may  be  multiple;  and  after  cure  by  obliteration  of  one  sac  others  may 
develop  (Fig.  204). 

The  sac  of  an  aneurysm  when  first  formed  contains  fluid  blood; 
the  eddying  and  partial  stagnation  to  which  this  is  constantly  sub- 


FiG.  207. — Saccular  aneurj-sm  with  large 
mouth;  when  opened  it  appears  as  if  there 
were  two  orifices. 


250 


SURGERY  OF  THE  BLOOD  VASCULAR  SYSTEM 


jected  leads  in  time  to  the  deposition  of  fibrinous  clots  on  the  interior 
of  the  sac  wall.  These  are  deposited  in  successi\e  layers,  constituting 
the  laminated  clot.  This  rarely  l)ecomes  firmly  adherent  in  all  spots 
to  the  sac  wall,  but  is  dissected  loose  by  the  eddying  currents,  thus 
preventing  its  organization.  Should  such  firm  adhesion  and  organiza- 
tion occur,  and  should  concentric  laminations  be  formed  continuously, 
spontaneous  cure  of  the  aneurysm  eventually  might  ensue  by  oblit- 
eration of  its  sac;  but  this  is  extremely  rare. 

Causes.— The  chief  underlying  cause  of  aneurysm  is  precedent 
disease  of  the  vascular  system;  aneurysm  is  but  a  symptom  of  this 
disease;  and  in  the  immense  majority  of  cases  the  vascular  degenera- 
tion is  a  sequel  of  syphilis, ^  though  chronic  alcoholism,  even  without 
syphilitic  affection,  is  saifl  sometimes  to  be  a  cause.  The  immediately 
apparent  cause,  in  most  cases,  is  some  sudden  strain,  exertion,  or 

accident,  which  causes  rui> 
ture  of  the  diseased  media  at 
its  most  susceptible  point; 
the  vis  a  tergo  of  the  blood- 
stream then  causes  progres- 
sive dilatation  of  the  artery 
until  a  well  defined  aneurysm 
exists.  Constantly  recurring 
slight  trauma  is  recognized  as 
a  predisposing  cause  in  that  it 
causes  localization  of  arterial 
lesions  where  aneurysms  later 
develop.  Thus  is  explained 
the  preponderance  of  aneu- 
rysm in  the  aortic  arch  and  at 
the  root  of  the  neck,  where 
not  only  is  the  cardiac  im- 
pulse strongest,  but  where 
the  arteries  lie  against  bone 
(vertebrse,  first  rib,  clavicle)  and  where  each  pulsation  tends  to  bruise 
the  arteries  against  this  unyielding  structure;  the  latter  explanation 
is  adduced  by  Barwell  (18S2)  to  account  for  the  frequency  of  popliteal 
(Fig.  208)  as  compared  with  brachial  aneurysm. 

Localization. — In  general  terms,  the  aorta  is  affected  in  42  per 
cent.,  the  popliteal  artery  in  24  per  cent.,  the  femoral  in  12  per  cent., 
and  the  carotid,  subclavian,  axillary,  and  innominate  in  about  3 
per  cent,  each — leaving  the  smaller  arteries  of  the  extremities  to  form 
about  10  per  cent,  of  cases  (Crisp,  1847).  Popliteal  aneurysm  forms 
from  55  to  60  per  cent,  of  those  occurring  in  the  limbs  (Matas,  1910). 
Age. — Aneurysm  occurs  mostly  in  patients  in  active  adult  life; 
about  two-thirds  of  cases  are  seen  between  the  ages  of  thirty  and 
fifty  years,   after  arterial  lesions  have  had   a   chance  to   develop, 


Fig.  208.^Poijliteal  aueurysni,  right  leg.     Dr. 
Harte's  case.     Pennsylvania  Hospital. 


1  This  was  streniiouslv  denied  bv  Barwell  (1882). 


SYMPTOMS  OF  AXE!'RyS.\f  251 

and  wliile  sudden  strains  arc  still  IVccjiiciit.  .SV'.r;  It  is  seen  in  men 
al)()ut  six  or  seven  times  as  fre(iuently  as  in  women,  owing  to  the 
greater  liability  of  the  male  sex  to  atheroma,  and  to  their  more  labori- 
ous life.  Occupations  attended  b.y  violent  exertion  (porters,  teamsters, 
soldiers,  sailors)  are  regarded  as  })redisi)osing  to  the  de\eloi)ment 
of  aneurysm,  as  are  diseases  of  the  heart  and  kidneys,  chronic  gout, 
rheiiniatisni,  etc.,  causing  arterial  hypertension  and  calcification. 

Symptoms. — These  usually  are  of  slow  develoi)ment,  though  occa- 
sionally the  ])atient  is  aware  that  "something  has  given  way,"  expe- 
riences a  sudden  stinging  pain,  as  the  "coup  de  fouet"  in  rupture 
of  deep  varicose  veins  (p.  243),  and  on  examination  at  once  finds  a 
pulsating  tumor  has  formed.  The  symptoms  of  aneurysm  may  be 
considered  as  those  peculiar  to  the  aneurysm  itself,  and  those  due  to 
its  pressure  on  surroundi}ig  parts.  There  is  present  a  rounded  or 
oval  tumor,  either  apparent  to  the  eye  or  appreciable  to  the  touch; 
it  is  situated  along  the  course  of  an  artery;  it  is  movable  laterally 
but  not  longitudinally  on  the  artery;  and  it  is  somewhat  compressible 
and  elastic  (depending  on  the  amount  of  laminated  clot).  An  aneurysm 
becomes  more  or  less  flaccid  by  pressure  on  the  artery  above,  and 
harder  and  more  tense  by  pressure  on  the  artery  below^  the  tumor. 
It  is  covered  by  healthy,  non-adherent  skin,  unless  in  the  last  stages 
when  rupture  is  about  to  occur.  The  affected  part  is  more  or  less 
disabled,  with  muscular  weakness,  paresthesia,  numbness,  or  edema 
(pressure  effects) :  pressure  on  nerves  causes  neuralgic  pain  or  paralysis 
(of  pupil,  of  vocal  cord,  etc.);  on  neighboring  veins  causes  varicosities 
and  edema;  on  arteries  (perhaps  the  parent  trunk)  causes  gangrene; 
on  bones  causes  erosion,  with  intense  boring  pain;  on  neighboring 
viscera  (trachea,  esophagus,  bile  ducts,  etc.),  may  cause  serious 
disturbance  in  their  functions.  Aneurysms  pulsate,  synchronously 
with  the  heart:  they  are  not  merely  lifted  by  the  pulsation  of  the 
underlying  artery,  but  as  the  blood  enters  the  sac  and  swirls  around 
in  its  interior  the  sac  walls  dilate,  causing  an  extremely  character- 
istic pulsation  wdiich  is  both  eccentric  and  expansile.  The  degree  of 
aneurysmal  pulsation  depends  on  the  size  of  the  sac  and  of  its  mouth, 
and  on  the  thickness  of  its  walls;  a  small  aneurysm  with  much  thick- 
ened walls  and  a  small  mouth  connecting  with  the  artery  will  pulsate 
much  less  than  one  w^hich  is  large,  thin  walled,  and  possessed  of  a  large 
mouth.  Pulsation  becomes  more  pronounced  when  the  part  is  depend- 
ent and  Avhen  pressure  is  made  on  the  artery  below  the  sac,  and  may 
almost  disappear  when  the  limb  is  elevated  and  the  artery  occluded 
above  the  sac.  When  pulsation  has  been  made  to  cease  b}'  the  latter 
method,  application  of  the  hands  over  the  sac  will  enable  the  surgeon 
to  detect  the  entering  blood  when  pressure  is  removed,  and  will 
make  him  appreciate  the  facts  that  the  sac  does  not  always  become 
fully  distended  with  the  first  impulse  from  the  heart,  and  that  the 
pulsation  is  eccentric  and  expansile,  driving  the  hands  not  only 
further  away  from  the  underlying  artery,  but  also  further  apart 
from  each  other.     Pulsation  in  the  artery  below  the  aneurysm  may  be 


252  SURGERY  OF  THE  BLOOD   VASCULAR  SYSTEM 

much  diminished,  as  compared  with  corresponding  pulsation  on  the 
other  side  of  the  body;  this  phenomenon  is  due  to  pressure  on  the 
artery  by  the  overlying  aneurysm;  while  the  fact  that  the  pulse  below 
the  aneurysm  may  be  delayed  is  explicable  on  mechanical  grounds, 
the  aneurysm  acting  as  the  air-chamber  of  an  hydraulic  ram.  INIore- 
over,  the  arterial  pressure  distal  to  the  aneurysm  is  less  than  in  the 
corresponding  healthy  artery.  Bruit,  which  is  the  peculiar  whirring 
or  rasping  noise  made  by  blood  entering  the  sac,  is  present  with  very 
few  exceptions  (old  thick-walled  aneurysms  almost  full  of  clot);  it 
occurs  during  cardiac  systole,  is  therefore  intermittent,  and  is  loudest 
in  aneurysms  with  large  sac  mouths;  it  may  be  made  to  cease  by 
obliteration  of  the  artery  above  the  aneurysm,  unless  large  collaterals 
empty  into  the  sac;  and  in  aneurysms  of  the  extremities  sometimes 
becomes  louder  when  the  limb  is  elevated.  It  may  be  transmitted 
centrifugally  along  the  diseased  artery.  Thrill  is  to  the  hand  what 
bruit  is  to  the  ear;  but  is  much  less  marked  than  in  arterio-venous 
aneurysms. 

Course  and  Termination. — Aneurysm  is  an  incurable  disease,  and 
if  left  to  itself  first  disables  and  then  kills  the  patient  within  com- 
paratively few  years.  Apparent  cure  is  only  temporary,  as  other 
aneurysms  ma}'  develop  or  the  first  recur.  By  proper  treatment, 
howe^Tr,  symptoms  may  be  relieved,  individual  aneurysms  may  be 
temporarily  cured,  and  the  life  of  the  patient  may  be  prolonged 
indefinitely  (perhaps  fifteen  to  twenty  years)  in  comfort  and  reasonable 
usefulness  (Fig.  204).  Death  finally  comes  slowly  (from  exhaustion, 
inanition,  gangrene,  etc.),  rapidly  (from  pressure  on  trachea  or  larynx, 
on  phrenic  or  pneumogastric  nerve,  from  rupture  and  hemorrhage, 
etc.),  or  suddenly  from  syncope  even  without  rupture. 

Diagnosis. — This  is  made  by  attention  to  the  history  and  physical 
signs.  Arterio-venous  aneurysms  usually  follow  penetrating  wounds; 
other  signs  of  vascular  disease  may  be  wanting;  bruit  is  continuous 
(not  intermittent  except  sometimes  when  the  limb  is  elevated — 
Nelaton),  is  transmitted  both  centrifugally  and  centripetally;  thrill 
is  marked;  and  compression  on  the  afferent  and  efferent  arterial 
trunk  does  not  cause  such  characteristic  changes  in  the  sac.  Other 
vascular  pulsating  tumors  are  less  well  defined  in  outline,  do  not 
present  eccentric  pulsation,  have  little  or  no  bruit,  and  are  not  neces- 
sarily placed  in  the  course  of  a  large  artery.  Other  tumors  may  pulsate 
because  they  overlie  an  artery,  but  the  pulsation  is  neither  expansile 
nor  eccentric,  there  is  neither  bruit  nor  thrill,  and  obliteration  of  the 
aft'erent  or  efterent  arterial  trunk,  while  it  may  cause  cessation  of 
pulsation,  yet  produces  no  other  change  in  the  tumor.  Xon-pulsating 
tumors  may  be  mistaken  for  an  aneurysm  with  contents  clotted;  such 
grow'ths  may  be  movable  longitudinally  as  well  as  laterally,  and 
present  a  different  clinical  history.  iVn  aneurysm  which  has  become 
diffused  or  inflamed  may  be  mistaken  for  an  abscess  (p.  49),  but 
attention  to  the  history,  and  a  careful  physical  examination  will 
almost  surely  prevent  any  confusion. 


TREAT  MEM'  OF  ANEL'in'^M  253 

Treatment.  -This  may  be  operative  or  non-operative.  Under  the 
latter  licadinu  are  inchuled  hyfjienic  and  dietic  measures,  such  as 
alone  are  aj)pli(al)le  to  certain  forms  of  internal  aneurysm.  All  other 
aneurysms  should  be  operated  upon,  and  nothing  is  gained  by  delay. 
The  end  sought  by  operation  is  to  prevent  blood  from  entering  the 
sac,  thus  allowing  its  obliteration.  This  may  be  attempted  in  various 
ways.  The  methods  still  in  most  general  use  endeavor  to  secure 
coagulation  of  the  blood  within  the  sac;  these  may  be  regarded  as 
palliative  operations.  ]\Iost  of  them  act  by  retarding  the  current  of 
blood  passing  through  the  parent  artery;  others  act  directly  on  the 
contents  of  the  sac  itself.  They  inchide  ])ressure  on  the  afferent 
artery;  compression  of  the  sac  itself  (as  by  flexing  the  knee  for  pop- 
liteal, or  the  hip  for  inguinal  aneurysm),  ligation  of  the  afferent  artery, 
or  of  the  efferent  artery  or  one  of  its  branches;  injection  of  coagulating 
fluids;  insertion  of  needles  with  irritation  of  the  intima  to  favor  throm- 
bosis; and  introduction  of  metallic  wire  with  electrolysis.  Manipula- 
tion of  the  sac  (Fergusson,  1857),  in  an  effort  to  detach  a  clot  which 
shall  plug  the  efferent  artery,  should  be  mentioned  only  to  be  con- 
flemned.  Radical  operations  comprise  extirpation  of  the  sac,  with 
suture  or  ligation  of  the  orifice  or  orifices  into  the  parent  artery; 
and  Endo-aneurysmorrhaphy,  which  is  the  best  method  whenever 
applicable. 

Pressure. — The  patient  should  be  confined  to  bed,  and  kept  on 
a  low  diet  with  very  little  fluid;  this  slows  the  circulation  and  favors 
thrombosis  (Tufnell,  1864).  The  pressure  may  be  either  instrumental 
(by  various  forms  of  tourniquets),  or  digital  (Knight,  1844),  which 
is  preferable.  The  afferent  artery  is  compressed  until  the  sac  ceases 
to  pulsate.  Relays  of  assistants  are  required,  each  one  keeping 
up  pressure  for  from  three  to  five  minutes,  being  then  relie\'ed  by 
another  who  compresses  the  artery  above  or  below  the  first  point 
of  compression  before  this  is  released  by  the  fingers  of  the  former 
assistant.  In  this  way  the  circulation  of  blood  in  the  sac  is  much 
diminished,  favoring  the  formation  of  a  laminated  coagulum.  Treat- 
ment is  to  be  kept  up  for  from  two  to  four  days,  in  sittings  of  about 
four  hours  once  daily.  After  thirty-six  hours  hope  of  cure  is  much  less, 
and  continuation  of  pressure  dangerous  (sloughing,  etc.).  The  method 
is  most  easily  applicable  to  the  femoral  artery,  for  aneurysm  of  the 
popliteal.  It  should  be  employed  only  when  endo-aneurysmorrhaphy 
or  ligation  are  contraindicated,  as  in  the  very  old  and  feeble,  in  those 
with  serious  visceral  disease,  etc.,  in  whom  the  dangers  of  a  cutting 
operation  are  excessive.  The  method  is  successful  in  perhaps  half 
the  cases  treated.  G.  Fischer  (1869),  found  that  among  188  cases 
of  aneurysm  treated  b}'  digital  compression,  cure  resulted  in  121 
(over  64  per  cent.),  and  38  of  these  patients  were  cured  in  less  than 
three  days;  of  90  cases  of  popliteal  aneurysm,  72,  or  79  per  cent., 
were  cured  by  digital  compression. 

LiGATiox. — This  may  be  done  on  the  proximal  side  of  the  aneurysm, 
or  the  distal,  or  on  both  sides. 


254 


SURGERY  OF  THE  BLOOD   VASCULAR  SYSTEM 


Froximal  Ligation. — The  method  of  Hunter  (1785)  consists  in 
applying  a  ligature  some  distance  above  the  aneurysm,  allowing  small 
branches  to  convey  blood  from  above  the  ligature  through  collateral 
circulation,  into  the  sac  of  the  aneurysm  (Fig.  209).  The  advantages 
claimed  for  the  Hunterian  method  are:  (1)  accessibility  of  the  artery; 
(2)  healthier  condition  of  the  arterial  walls;  (3)  gradual  obliteration 
of  the  sac  by  formation  of  laminated  clot.  But  modern  aseptic  oper- 
ating renders  the  artery  easily  accessible  at  any  site,  and  even  if 
the  arterial  wall  be  diseased  close  to  the  sac  (which  is  not  certain), 
application  of  a  ligature  will  strengthen  it,  and  healing  will  occur 
normally.  Objections  to  Hunter's  operations  are:  (1)  the  existence 
of  collateral  circulation  through  the  sac  really  is  unfavorable  to  its 


Fig.  209. — Hunter's  method  of  liga- 
tion for  aneurysm:  collateral  circula- 
tion from  above  the  ligature  into  the 
sac. 


Fig.  210. — Anel's  method  of  ligation  for 
aneurj-sm:  circulation  through  the  sac  com- 
pletelj'  arrested. 


complete  obliteration;  (2)  interposition  of  two  obstacles  to  the  circu- 
lation (ligature  and  aneurysm)  renders  gangrene  more  likely,  as  does 
the  exclusion  from  the  circulation  of  collaterals  arising  between  the 
ligature  and  the  sac;  (3)  if  the  collateral  circulation  is  successfully 
established  through  the  main  trunk,  recurrence  of  the  aneurysm  is 
likely.  The  method  of  Anel  (1710),  revived  in  1856  by  Broca,  con- 
sists in  the  application  of  a  ligature  close  to  the  sac  (Fig.  210);  until 
recent  years  it  was  considered  inferior  to  Hunter's  operation,  but 
aseptic  technique  has  shown  it  to  be  quite  as  safe  and  but  slightly 
more  difficult;  and  its  manifest  advantages  are  that  the  circulation 
through  the  sac  is  completely  suppressed  and  yet  no  additional 
obstacle  is  erected  to  the  circulation,  only  one  set  of  anastomosing 
vessels  being   required,   instead   of  two,  as   in   Hunter's  operation. 


THE ATM EXT  OF  ANEURYSM 


255 


jNIatas,  Di'lhct,  WoIht,  Kolilor,  LeCoiito  and  Stewart  all  jjrefer  Aiiel's 
metluxl  to  that  (jt"  Hunter. 

Distal  lUjatioii  also  depends  for  its  curative  effect  on  retardation 
of  the  circulation  within  the  artery,  with  consequent  thrombosis  in 
the  aneurysmal  sac.  Bnmlors  wet  hod  (1798)  consists  in  ligation  of  the 
main  trunk  immediately  distal  to  the  aneurysm,  no  branch  intervening 
(Hodgson,  1815)  (Fig.  211);  while  the  ''new  operation"  of  Wardrop 
(1828)  involves  ligation  of  one  of  the  main  branches  below  the  sac, 
or  of  the  parent  trunk  below  the  origin  of  a  })ranch  (Fig.  212).  These 
methods  are  inferior  to  proximal  ligation,  because  less  certain;  but 
are  still  employed  in  places  where  the  proximal  side  of  the  artery  is 


Fig.  211. — Brasdor's  method  of  liga- 
tion for  aneurysm,  applied  for  aneurysm 
of  the  common  carotid  artery  (C).  I, 
innominate;  S,  subclavian  artery. 


Fifi.  212. — Wardrop's  method  of  liga- 
tion for  aneurysm,  applied  for  aneurysm 
of  the  innominate  (/).  The  common 
cartoid  (C),  and  the  subclavian  (S)  in  its 
third  portion  have  been  ligated,  permit- 
ting slight  circulation  through  the  thy- 
roid axis. 


inaccessible,  as  in  Innominate  Aneurysm,  or  large  aneurysms  of  the 
first  part  of  the  Subclavian.  For  innominate  aneurj^sm  simultaneous 
double  ligation  of  the  common  carotid  and  subclavian  arteries  is 
preferred,  constituting  Wardrop's  method,  since  the  subclavian  is 
tied  in  its  third  portion  below^  the  origin  of  the  thyroid  axis  and 
vertebral. 

Double  Ligation,  Above  and  Below  the  Sac. — When  this  is  immedi- 
ately followed  by  incision  of  the  aneurysm,  evacuation  of  the  clots, 
and  packing  of  the  sac,  to  control  hemorrhage  from  collaterals  entering 
the  sac,  it  constitutes  the  operation  of  Antyllus  (third  century,  a.d.); 
if  the  sac  is  opened  first,  the  clots  evacuated,  the  mouth  of  the  sac 


256  SURGERY  OF  THE  BLOOD   VASCULAR  SYSTEM 

sought  with  tlie  finger,  and  a  probe  passed  up  and  down  the  parent 
trunk  as  a  guide  to  the  appHcation  of  Hgatures  above  and  below 
the  tumor,  it  constitutes  the  "old  operation,"  which  was  temporarily 
revived  by  Syrae  QSoT). 

At  the  present  time  the  mortality  from  ligation  is  about  8  per  cent.; 
there  is,  however,  also  the  risk  of  gangrene,  requiring  amputation, 
which  occurs  in  an  additional  S  per  cent,  of  cases  (Delbet).  Gangrene 
is  due  not  only  to  sudden  arrest  of  the  circulation,  but  also  to  pressure 
on  surrounding  tissues  by  the  thrombosed  sac,  and  sometimes  to 
embolism  of  the  artery  below  the  sac.  E\en  if  a  patient  recovers 
and  escapes  gangrene,  the  symptoms  from  pressure  (neuritis,  edema, 
etc.),  may  be  not  only  unrelieved  but  even  aggravated  by  solidifica- 
tion of  the  sac. 

FiLiPi-xcTURE  AXD  Electrolt.sis;  Wirinx.  of  Axeurysms. — 
Wiring  was  intrcxluced  by  Moore  (1864),  and  modified  by  Corradi 
(1879)  who  passed  an  electric  current  through  the  wire  coil.  Fine 
gold  or  silver  wire  fXo.  28  gauge)  is  used,  being  inserted  through  a 
cannula  which  is  plunged  into  the  aneurysmal  sac;  from  ten  feet  to 
as  many  yards  of  wire  are  introduced;  the  positive  pole  is  attached 
to  the  wire  entering  the  aneurysm  (Hare,  1908),  the  negative  pole 
being  placed  elsewhere  on  the  patient's  body,  and  the  current  (70 
to  SO  milliamperes)  is  allowed  to  run  for  nearly  an  hour.  This  method 
may  be  attempted  in  certain  cases  of  internal  aneurysm  in  which 
death  is  imminent  from  rupture,  or  in  which  Tufnell's  treatment 
(p.  253)  (perhaps  combined  with  repeated  venesection — ^^'alsalva's 
method)  fails  to  relieve  urgent  pressure  s\Tnptoms,  but  in  which  liga- 
tion or  endo-aneurysmorrhaphy  are  impossible.  Thoracic  aneurysms 
(aortic  arch,  low  innominate)  are  to  be  localized  by  physical  exami- 
nation and  the  ^-ray,  and  the  camiula  plunged  directly  into  the  sac; 
abdominal  aneurysm  is  treated  after  exposing  the  sac  by  laparotomy. 
For  thoracic  aneurysm  no  other  surgical  treatment  is  possible,  except 
in  the  case  of  innominate  aneurysm,  when  simultaneous  double  distal 
ligation  is  preferable.  In  some  cases  of  abdominal  aneurysm  endo- 
aneurysmorrhaphy  can  be  performed,  and  is  preferable  if  temporary 
control  of  the  circulation  can  be  secured.  ^latas  (1900)  found  that 
wiring  and  electrolysis  resulted  m  apparent  recovery  in  less  than  20 
per  cent,  of  cases;  in  1910  he  condemns  the  method  as  a  '"pureex- 
p>eriment,  which  is  justified  solely  by  the  imminent  and  unavoidable 
danger  of  death  from  the  progress  of  the  disease  itself."  Eshner 
(1910)  has  analyzefl  36  cases  of  aneurysm,  mostly  aortic,  treated  by 
wiring;  9  patients  died  within  ten  days,  22  lived  less  than  one  year, 
and  5  survived  for  periods  ranging  from  fourteen  months  to  over 
eleven  years. 

ExTiRPATiox  OF  THE  Sac,  known  by  the  names  of  Philagrius 
(third  century  A.  D.),  and  Purmann  (1685),  now  finds  an  ardent 
supporter  in  Delbet.  It  removes  the  danger  of  gangrene  due  to  pres- 
sure on  surrounding  parts  by  the  clot-filled  sac,  as  also  the  danger  of 
embolism.     For  its  successful  performance  it  is  necessary  to  secure 


T  RE  ATM  EST  Ob'  AMCIUYSM 


lot 


preliininan'  control  of  the  circulation,  when  possible  Ijy  iij)plication 
of  an  elastic  hand  at  the  root  of  the  linil),  or  even  hy  direct  clamp- 
ing of  the  afferent  and  efferent  artery.  This  latter  method,  however, 
may  not  prevent  profuse  recurrent  hemorrhaj^e  from  collaterals 
empty inj^  into"  the  sac.  The  vein  should  be  ])reserved,  and  if  impor- 
tant structures  are  adherent  to  the  sac  that  jxtrtion  of  the  sac  should 
be  left  behind.  According  to  Delbet  (19U7),  among  8()  patients 
treated  by  extirpation  of  the  sac  there  were  no  deaths,  and  gangrene 
followed  in  less  than  )>  per  cent. 


Vu:.  21.i. 


-Obliterative  cndo-aneurysni- 
orrhaphy. 


Fig.  211. — Restorative endo-anciirysm- 
orrhaphy. 


Fig.  215. — Reconstructive  endo-ancurysmorrhaphy. 


Endo-axeurysmorril\.phy,  introduced  by  ]\Iatas  in  1888.  After 
controlling  the  circulation,  the  sac  is  opened:  (1)  If  a  fusiform 
aneurysm,  or  a  saccular  aneurysm  with  very  large  mouth  (Fig.  207), 
is  found,  the  sac  is  obliterated  by  a  series  of  fine  chromic  catgut  or 
silk  sutures,  approximating  its  walls,  and  occluding  the  lumen  of  the 
17 


258  SURGERY  OF  THE  BLOOD   VASCULAR  SYSTEM 

artery  adjacent  to  the  mouth  of  the  sac  {Ohliicrative  Endo-aiiriiri/stuor- 
raphy  (Fig.  213).  (2)  If  a  saccular  aneurysm  with  small  mouth  is 
found,  it  may  be  possible  to  suture  the  margins  of  the  sac  mouth  with- 
out occluding  the  lumen  of  the  i)arent  artery  (Fig.  214).  Orifices  of 
collaterals  are  then  sutured,  and  the  sac  walls  approximated  as  before 
{Restorative  Endo-aneurysmorrhaphy) .  (3)  In  rare  cases  the  form  of  the 
aneurysm  may  be  such  that  it  will  be  possible  to  reconstruct  l)y  suture 
a  channel  to  represent  the  lumen  of  the  parent  artery,  though  little  or 
no  evidence  of  such  a  channel  exists  when  the  sac  is  opened;  a  soft 
catheter  may  be  used  as  a  guide  (Fig.  215)  (Reconstructive  Endo- 
aneurysmorrhaphy  or  Aneurysmoplasty .) 

The  methods  of  ]\Iatas  possess  over  ligation  all  the  advantages  of 
extirpation  (less  mortality  and  diminished  risk  of  gangrene)  while  at 
the  same  time  they  entail  less  trauma  than  extir])ation,  and  in  the 
restorative  and  reconstructive  methods  atl'ord  the  possibility  of 
preserving  the  circulation  through  the  parent  artery;  and  even  if 
this  circulation  is  preserved  only  temporarily,  gangrene  is  less  likely 
than  if  the  circidation  is  occluded  immediately  as  in  extirpation. 
If  endo-aneurysmorrhaphy  is  applied  to  cases  of  traumatic  aneurysm, 
this  should  not  be  until  a  firm-walled  adventitious  sac  has  formed. 
Matas  in  1910  collected  reports  of  110  cases  of  endo-aneurysmorrhaphy 
(including  67  aneurysms  of  the  lower  extremity),  with  only  two 
deaths  (1.8  per  cent.)  attributable  to  the  operation,  and  4  cases  of 
gangrene  (3.6  per  cent.),  3  of  which  were  chargeable  to  complications, 
not  to  the  operation  itself. 


riTAPTKR    XL 

SURGERY  OF  THE  SKIN,  BURS.^^],  LYMPHATICS, 
.MLSCLES,  TENDONS,  AND  NERVES. 

SURGERY  OF  THE  SKIN. 

Verruca  or  Wart. — This  is  a  localized  hyperplasia  of  the  epidermis, 
and  theoretically  may  be  distinjiuished  from  a  jKipiUoma,  which, 
as  noted  at  j).  IIS  is  a  neoplasm.  The  fa\'orite  sites  for  warts  are, 
the  hands,  face,  scalp,  and  neck.  They  iisnally  apj)ear  to  grow  spon- 
taneously, but  in  a  few  cases  a  suspicion  of  contagion  exists;  trauma 
followed  by  moisture  seems  a  predisposing  cause.  They  show  little 
tendency  to  enlarge,  scarcely  ever  become  malignant,  and  occasionally 
disap])ear  from  no  apparent  cause.  Treatment  is  sought  for  dis- 
figurement, sometimes  for  pain.  Removal  is  accomplished  easily 
by  snipping  off  the  warts  with  scissors,  after  spraying  with  ethyl 
chloride;  the  base  is  then  cauterized  with  silver  nitrate.  Or  by  apply- 
ing a  drop  or  so  of  fuming  nitric  acid  every  few  days,  the  warts  will 
in  time  shrivel  up  and  fall  oft'  painlessly.  Recurrence  is  rare  after 
thorough  removal. 

Venereal  warts  are  those  growing  upon  the  genitals  or  around  the 
anus;  they  are  due  to  irritation  from  uncleanliness,  and  have  no 
necessary  connection  with  any  venereal  disease. 

Callositas  or  Tyloma  is  a  dift'use  hypertrophic  condition  of  the 
skin,  normally  present  to  a  slight  degree  in  the  palms  and  soles, 
and  due  to  intermittent  pressure.  It  becomes  of  surgical  interest 
when  the  hypertrophy  is  so  great  as  to  cause  the  lesion  to  approach 
to  that  of  Claxus  or  Corn:  in  this  lesion  (which  frequently  develops 
in  the  centre  of  a  callosity,  or  may  arise  independently,  especially 
on  the  toes)  the  intermittent  pressure  causes  a  pyramidal  shaped 
up-growth  of  epithelial  cells,  which  presses  upon  and  finally  separates 
the  papilke  of  the  skin,  and  causes  exquisite  pain  from  pressure  on 
the  highly  sensitive  nerve-endings  found  in  this  layer.  A  soft  corn 
is  distinguished  from  a  hard  corn  by  the  fact  that  the  former  is  placed 
where  its  surface  is  kept  warm  and  moist,  as  between  the  toes;  while 
the  hard  corn  develops  on  an  exposed  surface.  When  of  long  duration 
a  bursa  may  be  formed  beneath  the  corn,  constituting  a  bunion; 
this  is  most  often  the  case  over  the  metatarso-phalangeal  articulation 
of  the  great  toe,  often  being  combined  with  hallux  vahiiis  (p.  549). 

Treatment. — Treatment  of  corns  consists  in  removal  of  the  cause; 
in  frequent  bathing;  application  of  such  plasters  as  will  relieve  the 
corn  from  pressure;  use  of  salicylic  acid  ointment  (5  to  10  per  cent.); 


260 


SURGERY  OF  THE  SKIN 


Fig.  216. — Hypertrophy  of  toe-nail,  or 
onychauxis,  one  year's  growth  since  the 
nail  was  last  cut  off.     Episcopal  Hospital. 


paring  the  surface  of  the  corn  (a  frequent  cause  of  celluHtis,  angeio- 
leucitis,  and  sepsis,  if  carelessly  done);  and  sometimes  in  formal 
excision. 

Cornu  Cutaneum  or  Horn,  is  a  rare  affection  of  the  skin,  most 
frequent  in  old  age,  and  about  the  face;  it  may  follow  the  spontaneous 

evacuation  of  a  wen.  Closely 
analogous  to  it  is  the  condition 
of  hypertrophy  of  toe-nails  or 
onychauxis  (Fig.  210).  Excision 
is  the  best  treatment. 
Keratosis  Senilis. — See  p.  022. 
Onychia.  —  Onychia  or  inflam- 
mation of  the  matrix  of  a  nail  is 
classed  as  simple  and  malignant. 
The  former,  or  "run-around,"  is 
most  frequent  in  children,  starting 
from  a  hang-nail,  and  appearing  as  a  red,  swollen,  tender  semicircle 
around  the  base  of  the  nail.  Treatment  consists  in  application  of  anti- 
septics, with  incision  as  soon  as  suppuration  is  suspected.  Malignant 
onychia  is  a  severer  form  of  the  disease,  occurring  in  persons  much 
debilitated,  and  often  coming  under  observation  only  in  the  stage 
of  ulceration  ("toe-nail  ulcer");  any  portion  of  the  nail  remaining 
should  be  removed,  the  granulations  curetted  or  cauterized,  and 
the  part  dressed  with  stimulating  ointments.  Hygiene  should  be 
attended  to,  and  tonics  prescribed.  Amputation  of  the  phalanx  may 
be  necessary  if  necrosis  occurs. 

Ingrowing  Toe-nail. — Ingrowing  toe-nail,  seen  almost  exclusively 
in  the  great  toe,  usually  is  due  to  ill-fitting  shoes,  which  produce  a 
degree  of  hallux  valgus  (p.  549) :  in  the  early  stages  the  form  of  the 
nail  is  unaltered,  but  the  soft  parts  of  the  pulp  are  crowded  over 
on  its  edge,  and  injudicious  trimming  of  the  nail  down'  this  chink 
predisposes  to  ulceration.  Later,  the  edge  of  the  nail  becomes  folded 
under,  and  by  pressure  on  the  pulp,  aggravates  the  condition.  If 
palliative  treatment  be  persisted  in  long  enough,  a  cure  usuall\'  may 
be  produced  by  keeping  the  parts  free  from  pressure,  and  separating 
the  overhanging  skin  from  the  nail  either  by  antiseptic  cotton  stuffed 
into  the  chink,  or  by  drawing  the  skin  aside  by  adhesi^'e  plaster, 
while  the  ulcer  is  treated  by  desiccating  powders  after  cauterizing 
its  base.  The  nail  should  be  cut  square  across  the  top,  and  never 
trimmed  down  at  the  sides.  If  a  rapid  cure  is  demanded,  it  is  best 
to  avulse  the  side  of  the  nail  affected  (both  sides  if  necessary)  by 
splitting  the  nail  down  the  centre  with  strong  scissors,  and  grasping 
the  portion  to  be  removed  in  forceps.  Local  anesthesia  is  sufficient. 
Tytler  (1909)  applies  a  tight  ligature  around  the  base  of  the  toe 
until  it  is  congested,  then  lightly  crushes  with  forceps  the  affected  half 
of  the  nail;  in  a  day  or  so  it  becomes  soft  and  bluish,  and  may  be  cut 
away  with  scissors.  As  the  new  nail  grows,  properly  fitting  shoes  must 
be  worn  to  prevent  recurrence. 


CARBUNCLE  261 

Perforating  Ulcer.  -Pcrfo rati  11^2;  ulcer,  usually  seen  in  the  sole 
of  the  toot  or  uii(l(T  tlu-  <;rfat  toe,  occurs  in  those  ])ast  middle  life, 
and  is  connected  with  arterio-sclerosis  or  tro])hi(,'  disturbances.  It 
occurs  in  diabetes,  and  in  locomotor  ataxia,  and  ]>robably  is  not  a 
specific  disease,  but  merely  an  evidence  of  tissue  destruction  due 
to  malnutrition.  It  is  not  attended  by  much  pain,  may  follow  slij^ht 
injury,  frost-bite,  etc.,  and  frecjuently  originates  in  a  small  slouf^h 
in  the  centre  of  a  callosity  or  corn.  If  untreated,  the  ulceration 
steadily  progresses,  eating  through  the  foot,  involving  muscles, 
tendon,  and  bone;  is  attended  by  a  stench,  and  in  advanced  stages 
jH'rforates  the  dorsum  of  the  foot.  Under  hygienic  measures,  internal 
administration  of  potassium  iodide,  rest  in  bed,  and  active  local 
treatment  (cleansing,  curetting,  etc.),  temporary  cure  sometimes  is 
obtained. 

Furuncle  or  Boil. — Furuncle  or  boil  is  an  infection  of  a  hair  follicle 
or  sebaceous  gland,  confined  to  the  deeper  layers  of  the  true  skin, 
usually  terminating  in  suppuration,  with  the  extrusion  of  a  central 
slough  called  the  core.  The  usual  cause  is  Staphylococcus  aureus, 
which  gains  entrance  through  a  minute  abrasion,  as  from  a  rough 
edged  collar  or  cufl".  Persons  with  disordered  metabolism  (diabetes, 
gout,  nephritis,  scrofula,  eczema,  etc.),  are  especially  predisposed  to 
furunculosis.  The  classical  symptoms  of  inflammation  are  present — 
a  red,  extremely  tender  and  painful  swelling,  attended  by  local  heat, 
in  the  true  skin  and  subcutaneous  tissues.  Boils  vary  much  in  size, 
but  seldom  appear  over  tw^o  inches  in  diameter;  they  usually  are 
multiple,  sometimes  appearing  in  successive  crops.  Boils  usually 
have  a  marked  tendency  to  point;  those  that  do  not,  are  called  "blind 
boils." 

Treatment. — Treatment  includes  such  general  hygienic  and  tonic 
measures  as  will  prevent  a  continuance  or  recurrence  of  the  boils; 
frequent  bathing,  with  the  use  of  alkalies  (sodium  carbonate)  in  the 
bath  and  by  mouth,  is  important.  By  local  treatment  in  the  \ev\ 
early  stages  it  sometimes  is  possible  to  abort  a  boil  by  pouring  pure 
ichthyol  oxev  its  surface,  and  making  a  scab  with  a  film  of  absorbent 
cotton.  In  most  cases,  however,  early  incision,  besides  relieving  pain, 
will  accelerate  extrusion  of  the  slough,  and  prevent  formation  of 
neighboring  boils,  which  are  encouraged  by  poulticing.  After  extract- 
ing the  core,  pure  ichthyol  may  be  poured  into  the  crater  of  the 
furuncle,  or  a  drop  of  carbolic  acid  may  be  introduced  on  a  match- 
stick.  The  surrounding  skin  must  be  kept  clean  and  stimulated  with 
astringent  washes.  In  cases  of  persistent  furunculosis,  much  benefit 
has  been  derived  from  the  administration  of  autogenous  ^'accines. 

Carbuncle. —  Carbuncle  may  be  regarded  as  an  aggravated  form  of 
boil  (Fig.  217).  The  infection  spreads  more  wideh^  in  the  subcutaneous 
tissues,  there  is  phlegmonous  inflammation,  and  the  pus  tends  to 
e^'acuate  itself  through  manifold  orifices,  by  following  the  course  of 
the  columnw  adiposop  (Warren,  1881).  Carbuncles  are  most  common 
on  the  nucha,  and  may  extend  almost  from  the  vertex  to  the  shoulder. 


262 


SURGERY  OF  THE  SKIN 


In  the  old,  the  diabetic,  the  subjects  of  advanced  Bri<;ht's  disease, 
etc.,  it  forms  a  very  serious  malady,  often  endanyerinu;  life.     There 

is  no  clear  limit  to  the  inflam- 
mation, which  usually  is  more 
widespread  than  is  apparent 
on  the  surface. 

Treatment.  —  Hygienic  and 
constitutional  treatment  is  even 
of  more  \alue  than  in  furun- 
culosis.  (1)  Small  carbuncles 
should  be  treated  as  boils,  by 
early  incision  which  may  be 
crucial  if  necessary,  to  facilitate 
extrusion  of  the  sloughs.  (2) 
Medium-sized  carbuncles  should 
be  incised  as  above,  and  then 
strapped  with  adhesive  plaster 
applied  concentrically,  until 
only  a  small  orifice  is  left  for 
the  discharge  of  pus  (Fig.  218) ; 
this  strapping,  suggested  by 
O'Ferral  (1858)  and  emphasized 
as  particularly  valuable  by  J. 
Ashhurst,  Jr.  (1809),  acts 
mechanically  by  [limiting  -^the 
spread  of  the  phlegmon  by  erecting  an  impassable  barrier  around 
the  base,  and  forcing   the  discharge  of  sloughs  through  the  central 


Fig.  217. — Carbuncle  of  neck;  duration, 
two  weeks;  incised  a  few  days  ago;  no  im- 
provement.    Episcopal  Hospital. 


1 

1 

^^^^B  V 

^^^H 

^^^V  "^ 

% 

^'^^^H 

1 

^^^^V^;^ 

^H 

HP^ 

x\ 

^^1 

\ 

vM^^^^I 

^^^^H 

F\:f\>:- 

^^ 

1 

Fig.  2  is. — Carbuncle  of  neck 
strapped  with  adhesive  plaster.  Epis- 
copal Hospital. 


Fig.  219. — Carbuncle  of  u'.'ck  after  .strap- 
ping for  one  week.  Only  a  suj^erncial  ulcer 
remains.     Episcopal  Hospital. 


opening;  it  secures  local  rest;  and  also,  I  believe,  creates  a  certain 
degree  of  passive  hyperemia  in  the  diseased  area,  thus  increasing  the 


Lcrcs  vrijLMus  2(;:5 

pliM^ocv  tic  and  (t|)s<>iiic  jxjwcrs  of  the  ])ati('iit.  The  stra|)|)iii^'  cliccks 
almost  at  once  the  excessive  pain  caused  l»y  tlic  carhuncle,  and  as 
it  nia.\  l)e  left  in  i)lace  for  several  days  at  a  time,  consi(leral)ly 
simplifies  the  treatment.  The  gauze  which  receives  the  discharf^e 
throuj:;h  the  central  oj)enin<i:  should  he  chanj^ed  daily.  'J'he  dimi- 
luition  in  size  of  the  carhuncle  (I'ig.  -\\))  evident  when  the 
strappinjf  is  removed  is  as  remarkable  as  it  is  gratifying.  Seldom 
more  than  two  or  at  most  three  straj)pings  are  required  to  convert 
an  angry  volcano  into  a  sui)erficial  ulcer,  which  readily  heals  under 
i)Iand  ointments.  ['.\)  W'ry  large  rarhintrles  sometimes  may  be  excised, 
with  benefit:  the  patient  being  anesthetized,  a  circular  incision  is 
made  at  the  apparent  outer  border  of  the  carbuncle;  this  incision 
is  carried  down  to  the  deej)  fascia  and  muscles,  which  rarely  are 
involved,  and  the  entire  sloughing  mass  is  cut  away;  l)leeding,  which 
may  be  profuse,  is  checked  by  ligature,  pressure,  or  cauterA';  and  the 
large  raw  surface  is  packed  with  absorbent  gauze,  which  should  not 
be  removed  for  four  or  five  days.  Free  stimulation  is  required  after 
the  oi)erati<)n,  and  skin-grafting  may  be  necessary  to  secure  final 
cicatrization. 

Tuberculosis  Cutis. — The  tuberculous  lesions  of  the  skin  of  most 
interest  to  surgeons  are  Luyus  Vulqaris,  Scrofuloderma,  and  Erythema 
Indnratiim. 

Lupus  Vulgaris. — The  tuberculous  lesions  are  seated  in  the  corium, 
and  usually  are  secondary  to  an  insignificant  focus  elsewhere.  The 
disease  occurs  in  young  persons  of  scrofulous  tendencies,  is  most 
frequent  in  the  face,  and  appears  as  one  or  several  minute  red  papules, 
tender  but  not  appreciable  to  touch,  which  on  examination  are  found 
to  be  covered  by  a  thin  pellicle  of  altered  skin,  giving  them,  when 
the  blood  is  pressed  out  by  application  of  a  glass  slide,  a  close  resem- 
blance to  drops  of  apple-jelly.  The  overlying  pellicle  is  soft  and  easily 
punctured,  the  probe  or  scalpel  sinking  for  some  millimeters  into 
the  diseased  area.  These  nodules  may  coalesce,  the  patch  spread- 
ing eccentrically  and  healing  in  the  middle,  and  thus  bearing  some 
resemblance  to  certain  of  the  syphilodermas;  but  the  apple-jelly 
nodules  can  be  seen  in  the  advancing  border  of  the  lupus  patch. 
\Yhen  lupus  ulcerates  (lupus  exedens,  as  distinguished  from  simple 
lupus,  or  lupus  non-exedens),  the  surrounding  tissues  may  be  widely 
destroyed,  but  the  ulcer  ahvays  remains  superficial;  its  outline  is 
rounded,  its  edges  are  not  indurated,  and  its  course  is  verv  slow 
(Figs.  220  and  221). 

Diagnosis. — This  must  be  made  by  careful  examination  to  detect 
the  apple-jelly  nodules,  by  attention  to  the  clinical  history  of  the 
patient,  and  by  exclusion  of  syphilis,  epithelioma,  or  other  rarer 
ulcerations  of  the  skin,  all  of  which  usually  occur  in  older  patients. 
Lupus  erythematosis,  thought  by  many  to  be  due  to  toxins  of  tubercle 
bacilli  lodged  elsewhere  in  the  body,  is  sufficiently  characterized  by 
its  usual  butterfly  outline,  its  persistent  redness,  the  absence  of  the 
apple-jelly  nodules,  and  its  unulcerated  condition. 


264 


SURGERY  OF  THE  SKIN 


Treatment. — The  treatment  includes  constitutional  anti-tu})erculous 
measures  (p.  .S2),  and  local  remedies.  The  latter,  whenever  possible, 
should  consist  of  excision,  replacing  the  loss  of  tissue  by  skin-grafting 
or  a  plastic  operation  (p.  023).  If  excision  cannot  be  done,  the 
diseased  spots  should  be  gouged  out  with  a  sharp  spoon,  and  the 
cavities  left  treated  with  strong  antiseptics  or  caustics,  lladiography 
is  of  value  in  some  mild  cases,  as  is  the  use  of  radium,  Finsen 
light,  etc.  \ 


i'u;.  L'L'O.-  l.upus  vulgaris  in  a  girl,  aged 
sixteen  years.  Four  years  ago  the  first 
lymph  node  swelling  appeared  under  the 
chin.  There  followed  tuberculous  lym- 
phangeitis,  which  involved  the  skin.  Two 
years  ago  invasion  of  nasal  mucosa  oc- 
curred, and  this  led  to  involvement  of  the 
skin  over  the  nose.     (Philippson.) 


Fig.  221. — Lupus  vulgaris  of  face,  in 
a  woman,  aged  thirty-eight  years;  the 
disease  began  twenty-three  years  ago  in 
the  left  cervical  lymph  nodes.  (Phil- 
ippson,) 


Scrofuloderma. — Scrofuloderma  is  the  name  given  to  the  tuber- 
culous lesion  of  the  skin  which  results  when  this  is  invaded  by  a 
tuberculous  process  in  an  underlying  structure,  as  a  caseous  lymph 
node.     The  condition  was  referred  to  at  p.  SO,  Fig.  36. 

Erythema  Induratum  or  Bazin's  Disease  (1855)  is  a  paratuber- 
culous  affection  usually  of  the  calves  of  the  legs  of  growing  girls 
with  a  scrofulous  taint;  it  appears  as  multiple  bluish-red  indurations, 
resembling  somewhat  both  furuncles  and  syphilitic  gummas,  which 
tend  to  soften  and  discharge,  leaving  indolent  and  very  painful 
ulcers.  These  can  be  made  to  heal  only  by  improving  the  general 
health. 

Erythema  Nodosum. — Erythema  nodosum  is  mentioned  merely 
to  w^arn  the  student  not  to  mistake  its  lesions  for  contusions  or 
abscesses.    The  affection  usually  is  bilateral,  occurs  in  children,  and 


SEIiACKOrS  CYST 


205 


in  most  casrs  tlic   shins  arc  aflVcted   (Fi^.  222),  tliouj^'li  sonu'tiincs 
t\\v  U'sions  ajjpear  over  the  sul)C'utanc()Us  surfaces  of  the  uhuc.    There 
is  no  history  of  trauma;  tlierc  is  more  constitutional  disturbance  than 
from   bruises;  and    often  the 
(Hscase   is  one   manifestation 
of  an  infection  (jnThaps  some 
attenuated   form   of  tubercu- 
K)sis)   which  causes  endocar- 
ditis, ])Icurisy,  etc. 

Acne  Rosacea. — See  p.  fi20. 

Epithelioma. — See  j).  (■)24. 

Sebaceous  Cyst  (Steatoma, 
Wen). — This  is  a  retention 
cyst,  due  to  occlusion  of  the 
orifice  of  a  sebaceous  duct. 
The    cysts,    which    may     be 


Fig.  223. — Sebacc-MU.-  i\,~t  mI  -raljj;  (iuratioii, 
thirtj'  years.    Episcopal  Hospital. 


f     * 

^^m     ' 

Fig.  222. — Erythema  nodosum. 
One  week's  duration,  following 
staphylococcic  infection  of  finger 
and  complicated  by  endocarditis. 
Temperature,  100.4°  F.  Episcopal 
Hospital. 


Fig.   224. — Scbaceou.s  cyst  of  ear.    Episcopal 
Hospital. 


multiple,  occur  mostly  in  the  scalp  and  face  (Figs.  223  and  224); 
on  the  extremities,  and  especially  below  the  level  of  the  umbilicus  they 
are  extremely  rare.  The  skin  is  adherent  to  the  cyst  at  one  point,  the 
orifice  of  the  duct,  sometimes  visible  as  a  black  dot;  the  cheesy,  malo- 
dorous sebum  usually  can  be  squeezed  out,  after  inserting  a  probe  into 


2()() 


IXJURIES  AXD  DISEASES  OF  BURS.E 


the  duct.  These  cysts  frequently  become  hiflamed  and  su})])urate; 
when  thev  discharge  spontaneously,  a  bleeding  fungous  mass  ])rotrudes 
which  may  be  mistaken  for  a  malignant  papilloma;  and  carcinomatous 
changes  are  not  unknown  (p.  553) .  If  the  discharge  of  sebum  crusts 
on  the  surface,  a  cutaneous  horn  (p.  260)  may  develop.  Some  seques- 
tration cysts  (p.  130)  are  clinically  indistinguishable  from  sebaceous 
cysts  (Fig.  220). 


Fig.    225. — Sebaceous   cyst    of 
ear  excised.     (See  Fig.  224.) 


Fig.  226. — Dermoid  cyst  of  scalp.    Children's 
Hospital. 


Treatment. — Wens  are  removed  easily,  under  local  anesthesia, 
by  dividing  the  overlying  skin  and  dissecting  the  unruptured  sac 
from  the  subcutaneous  tissues,  to  which  its  adhesions  are  light. 
Recurrence  is  frequent  unless  all  the  cyst  wall  is  removed.  If  of 
large  size  some  of  the  overlying  skin  may  be  excised. 

Pilo-nidal  Cysts  and  Fistulae. — These  are  a  form  of  sequestration 
cysts,  mentioned  at  p.  130.  They  occur  most  often  in  the  region  of 
the  anus,  and  may  be  congenital  or  acquired.  According  to  Hodges 
(1880)  only  the  sinus  is  congenital,  and  the  hairs  work  their  way  in 
during  post-natal  life,  finally  occluding  the  orifice  of  the  sinus  and 
forming  a  cyst.  Suppuration  is  frequent.  Excision  is  the  proper 
treatment  (Klemm,  1909). 


INJURIES  AND  DISEASES  OF  BURS^. 

Wounds  of  Bursae. — If  the  bursa  opened  communicates  with  a 
joint,  serious  consequences  may  follow;  and  as,  in  the  case  of  a  bursa 
which  sometimes  communicates  with  a  joint,  the  fact  of  its  non- 
communication can  never  be  known  a  priori,  all  such  cases  should 
be  treated  as  if  a  joint  was  involved  (p.  386).  If  the  wound  is 
punctured,  it  should  be  enlarged,  after  suitably  cleansing  the  part; 
and  foreign  matter  should  be  extracted,  the  bursa  drained,  and  local 
and  constitutional  rest  provided.  If  no  infection  follows,  the  bursa 
will  heal  with  partial  or  complete  obliteration  of  its  cavity.  If 
suppuration  occurs,  daily  irrigation  of  the  bursa  should  be  done  as 


BURSITIS 


2()7 


soon  as  it  is  r\i(l(Mit  that  no  profiress  toward  iK-aliiifi  is  hciii^-  inaile 
iiKTelx  l)y  draiiia.iit'.  l''iiiall\ ,  the  bursa  may  he  excised  if  coiitimiaiice 
in  eoiiser\ati\e  treatiiu-nt  is  inell'ectiial. 


I'k;.  227. — Pioiiatcllar  Inusiti.s:  two 
months'  duration;  subacute  onset.  Epis- 
copal Hospital. 


Fig.  22  >.  — Olccianon  Inn. sit  is,  two 
months'  duration;  no  acute  trauma.  Epis- 
copal Hospital. 


Bursitis. — Bursitis,  or  inflammation  of  a  bursa,  usually  follows 
contusions,  and  may  be  acute  or  chronic.  Acute  bursitis  follows 
slight  continuous,  or  frequently  intermitted  trauma,  as  in  the  retro- 
calcaneal  bursa  {Achillodynia  or  Albert's  disease,   1893),  or    in    the 

olecranon  bursa  in  those  confined  to  bed, 
with  gouty  tendency.  Relief  of  pressure, 
evaporating  lotions,  and  rest,  usually  cause 
subsidence  of  the  inflammation  in  a  few 
hours.  If  suppuration  occurs,  early  free 
incision  should  be  made.  Chronic  Bur- 
sitis, which  follows  slight  but  continually 
repeated  trauma,  may  be  a  sequel  of 
acute  bursitis  or  may  be  chronic  from 
the  start.  The  bursae  most  often  af- 
fected are:  (1)  Prepatellar  ("Housemaid's 
Knee,"  Fig.  227);  (2)  Olecranon  ("Miner's 
Elbow,"  Fig.  228);  or  (.3)  the  bursa  over 
the  Tuber  Ischii   ("Weaver's  Bottom"). 


Fig.  229.  —  InHanimation  of 
bursa  beneath  tendo  iiatella?, 
bulging  on  inner  side  of  tendon. 
Acute  onset  three  days  ago,  from 
acute  flexion  of  knee.  "Dis- 
persed" by  a  blow.  Episcopal 
Hospital. 


Fig.  230. — Ganglion  in  bursa  of  biceps  brachii  at 
insertion.     Episcojial  Hospital. 


268  INJURIES  AND  DISEASES  OF  THE  LYMPHATICS 

Other  bursts  sometimes  aflFected  are:  (4)  Siil)acromial  Bursa  (see 
Periarthritis,  \).  4(i6);  (5)  that  beneath  the  Tendo  Patellae  (Fig. 
229) ;  (6)  those  over  the  Femoral  Condyles  (see  Ganglion  of  Popliteal 
Space,  p.  281);  (7)  Subgluteal  Bursa;  (8)  that  over  the  head  of  the 
first  metatarsal  bone  (see  Bunion,  p.  259,  and  Hallux  Valgus,  p.  549); 
(9)  between  the  tendon  of  the  Biceps  and  tuberosity  of  the  Radius 
(Fig.  230).  By  coagulation  of  the  effused  fluid,  solid  enlargement  9f 
a  bursa  may  occur. 

Treatment. — Treatment  of  chronic  bursitis  consists  in  removal 
of  the  cause,  application  of  sorbefacient  ointments,  painting  with 
tincture  of  iodin,  etc.;  and,  these  failing,  in  tapping  and  injection 
of  2  per  cent,  formalin-glycerin  solution  or  dilute  alcohol  (never  when 
joint-communication  may  exist),  in  incision  and  drainage  (when 
healing  will  occur  by  obliteration  of  the  sac),  or  in  excision  which 
is  best  in  most  cases,  especially  those  of  long  duration  with  thick 
sac  walls. 

INJURIES  AND  DISEASES  OF  THE  LYMPHATICS. 

Wounds. — Wounds  of  the  lymphatics  are  of  little  moment  escept 
when  the  thoracic  duct  is  injured,  as  it  may  be  in  operations  on  the 
neck.  If  this  accident  is  discovered  when  the  wound  is  inflicted  (by 
a  discharge  of  milky  fluid  in  the  wound — lymiihorrhea) ,  an  attempt 
should  be  made  to  apply  a  lateral  suture.  If  this  is  impossible, 
both  ends  of  the  duct  should  be  ligated;  and  this  failing,  the  wound 
should  be  tamponed.  If  the  injury  is  not  discovered  at  the  time  of 
operation,  it  soon  makes  itself  manifest  by  a  discharge  of  chyle  from 
the  wound,  and  by  rapid  and  progressive  emaciation.  There  should 
be  no  delay  in  reopening  the  wound  and  suturing  or  ligating  the 
duct.  Fredet  (1910)  collected  58  cases  of  injury  to  the  thoracic 
duct,  with  five  deaths. 

Lymphorrhea. — Lymphorrhea  may  also  occur  from  wounds  of 
lymphangiectases  (p.  2()9), 

Chylothorax  and  Chylous  Ascites  occasionally  follow  rupture  from 
contusion  of  the  thoracic  or  abdominal  portions  of  the  thoracic  duct. 
Repeated  tapping  of  the  thoracic  or  abdominal  fluid  has  resulted  in 
cure  in  a  few  cases.  Certain  chylous  cysts  of  the  mesentery  (Chapter 
XXIII)  have  a  similar  origin.  Chyluria  may  result  from  communica- 
tion with  the  urinary  tract. 

Lymphangeitis  or  Angeioleucitis,  inflammation  of  lymphatic  vessels, 
usually  is  due  to  spread  of  infection  from  a  wound.  It  is  seen  most 
often  on  the  extremities,  but  I  have  seen  it  on  the  abdomen  as  a  result 
of  omphalitis.  There  are  one  or  several  flame  red,  irregular  streaks 
running  from  the  site  of  infection  (felon,  lacerated  woimd,  etc.)  up 
to  the  axillary  or  inguinal  lymph  nodes;  these  streaks  coalesce  here 
and  there  to  form  broader  red  bands,  and  may  again  separate  before 
reaching  their  terminus  (Plate  I,  Fig.  1).  They  are  not  particularly 
painful  or  tender,  seldom  are  palpable,  and  are  redder  and  less  regular 


L  YMF  II A  NGIECTA  SIS 


2G9 


in  tlioir  course  than  veins  in  cases  of  plilehitis  (p.  '2'M)).  There  is 
considerable  fever,  cliills  may  occur,  and  lymphadenitis  usually 
co-exists.  Treatment  consists  in  cure  of  the  focus  of  infection;  in 
local  rest  by  si)lints,  confinement  to  bed,  etc.,  and  in  applications  of 
silver  nitrate,  dilute  iodin,  ichthyol,  etc.,  along  the  course  of  the 
inflamed  lymphatics.  Su])])uration  frecpiently  occurs  in  the  lymph 
nodes,  but  seldom  along  the  lym])h  vessels. 

Lymphadenitis.  Lymj)hadenitis,  or  simply  "adenitis,"  occurs  as 
an  incident  in  cases  of  lymj)hangeitis,  but  may  also  occur  when  no 
evidences  of  superficial  lymphangeitis  exist. 
Thus  femoral  or  inguinal  adenitis  (bubo) 
frc(|uently  follows  a  blister  of  the  foot,  or 
venereal  or  other  infection  of  the  genitals, 
when  no  sign  of  lymphangeitis  can  be  de- 
tected (Fig.  231).  Epitrochlear  or  axillary 
adenitis  may  arise  from  a  slight  abrasion  or 
pimctured  wound  of  the  hand  which  healed 
before  the  secondary  lesion  was  noticed. 
The  symptoms  are  those  usual  in  inflam- 
mation, and  the  tender,  enlarged  lymph 
nodes  are  distinctly  palpable.  Suppuration 
is  not  unusual.  Secondary  invasion  by 
specific  microbes  (chancroidal,  tuberculous) 
may  occur,  and  somewhat  changes  the 
character  of  the  lesion.  Any  lymphadenitis 
which  assumes  a  subacute  or  chronic  course 
is  liable  to  infecton  with  tubercle  bacilli 
through  the  blood-stream.  This  is  espe- 
cially true  of  cervical  adenitis  (p.  676). 
Chancroidal  bubo  is  discussed  in  Chapter 
XXVI. 

Treatment. — Treatment  of  adenitis  im- 
plies cure  of  the  source  of  infection;  anti- 
phlogistic   applications     to   the    seat    of 

adenitis ;  early  incision  in  case  of  suppuration ;  and  finally  formal  exci- 
sion of  the  diseased  mass  of  lymph  nodes  if  the  resulting  sinus  fails 
to  close  under  conservative  treatment  or  if  the  lymph  nodes  remain 
enlarged  and  tender  without  the  occurrence  of  suppuration. 

Lymphangiectasis. — Lymphangiectasis,  or  dilatation  of  lymph 
channels,  results  from  obstruction  to  the  flow  of  lymph.  This  may 
be  due  to  external  pressure  (as  from  tumors  or  cicatrices);  to 
operative  removal  of  the  nodes  draining  the  part;  or  it  may  be 
caused  by  chronic  lymphangeitis,  causing  obliteration  of  the  main 
lymph  vessels,  often  following  repeated  attacks  of  erysipelas,  etc. 
It  is  much  rarer  as  a  consequence  of  external  pressure  than  is 
phlebectasis  (p.  242),  because  the  lymphatic  collateral  circulation 
is  much  freer.  Sometimes  it  affects  the  spermatic  cord,  constituting 
a  lymphatic  varicocele.    When  a  distinctly  localized  swelling  is  formed, 


Fig.  231. — Femoral  lymph- 
adenitis; duration,  two  days; 
from  infected  wound  of  left  foot 
two  weeks  ago.  Episcopal 
Hospital. 


270  INJURIES  AND  DISEASES  OF  THE  LYMPHATICS 

it  is  known  as  Ii/mphancjeionia;  this  occurs  oftenest  as  a  congenital 
condition  in  the  face  or  neck,  but  may  develop  in  adult  life  (Fig.  232). 
It  forms  a  soft  fluctuating  swelling,  covered  by  healthy  skin. 
Excision  is  the  proper  treatment,  but  if  complete  extirpation  is  im- 
possible, a  partial  operation  entails  great  risk  of  lymphorrhagia, 
with  malnutrition;  in  such  cases  galvano-puncture  may  be  tried. 
Macromelia,  or  giant  growth  of  a  part,  usually  is  a  lymphangeio- 
matous  condition;  one  finger,  the  lips,  the  tongue,  etc.,  may  be 
affected. 


Fig.     232. — Lymphangeioma    of    right 
foot,  aged   seventy-five    years;    duration,        Fig.  23.3. — Lymphedema:  duration,  one 
seven  years.    Orthopedic  Hospital.  year.    Episnopal  Hospital. 

Lymphedema,  resulting  from  lymphangiectasis,  and  consisting  of 
thickening  of  the  subcutaneous  tissues  from  the  effused  fluid  with 
cellular  reaction,  occurs  principally  in  the  lower  extremity  (Fig.  233), 
often  associated  with  chronic  ulcer;  or  in  the  upper  extremity  follow- 
ing ablation  of  mammary  carcinoma  and  axillary  lymphatics  (Fig. 
744).  Ilereditary  persistent  edema  of  the  legs,  w^hich  has  been  studied 
by  Jopson  (1898),  is  believed  by  Hope  and  French  (1908)  to  be  a 
vascular  neurosis,  causing  hard  edema,  which  terminates  abruptly  at 
the  knee  or  groin,  there  being  no  evidence  of  venous  or  lymphatic 
obstruction;  but  the  result  is  very  like  lymphedema.  If  palliati^'e 
treatment  (bandaging,  massage,  etc.)  fails,  various  operative  measures 
may  be  undertaken.  Excision  of  wedge-shaped  longitudinal  strips 
of  the  thickened  skin  and  cellular  tissues  may  reduce  the  bulk  of 
the  limb  so  as  to  promote  ease  in  locomotion.  Lymphangeio plasty 
(Handley,  1908)  consists  in  inserting  long  strands  of  silk  in  the  sub- 
cutaneous tissues  from  the  hand  or  foot  to  the  axilla  or  groin;  these 
act  as  capillary  drains  and  rapidly  reduce  the  edema.  Lanz  (1911) 
drilled  holes  into  the  medulla  of.  the  femur  and  inserted  into  them 
strips  of  fascia  lata  still  attached  by  one  end,  thus  creating  new 


ii()J)(;kl\'s  disease 


271 


duimu'ls  of  (Iniinii^c  tlironuli  i\\v  iniirn»\v  caxity.     Aiii))nt;iti(tii  is  tlic 
last  resort. 

Elephantiasis  Arabum  is  a  form  of  lympliedenia  duv  to  ohstniction 
of  lyinpli  clianiu'ls  hy  filaria  ffanoNi'nl.s  homijii.s,  the  disease  l)einf; 
called  filaridsis.  The  ])arasite  is  transferred  from  patient  to  patient 
through  a  ni()S((iiito  as  intermediary  host.  In  the  ])atient  the  half 
grown  parasites  l()d<i;e  in  the  })eripheral  lynii)hatics,  th<'re  heeome 
matnre  and  ])r()dnee  ()lfs])ring.  The  emhryos  enter  the  hlood-stream, 
bnt   ap])ear   in   the   ])eripiieral   circnlation   only   at    niyht;   when   the 


Fig.  234. — Persistent  hereditary  edema  af- 
fecting two  brothers.  (See  Fig.  235.)  (Dr. 
Jopson's  cases).    Children's  Hospital. 


Fig.  235. — Persistent  hereditary 
edema,  in  two  brothers.  (See  Fig. 
234.)  (Dr.  Jopson's  cases).  Chil- 
dren's Hospital.) 


patient  is  at  rest  they  are  readily  abstracted  thence  by  the  mosquito. 
Elephantiasis  afl'ects  the  lower  extremities  and  the  scrotum  more 
often  than  other  parts  of  the  body.  It  is  rare  in  this  country,  except 
in  persons  recently  returned  from  the  tropics.  Treatment:  Palliation 
is  secured  by  support,  bandaging,  etc.,  but  excision  usually  is  indi- 
cated.   Amputation  may  be  necessary. 

Hodgkin's  Disease  (1832)  (Malignant  Lymphoma,  Lymphomatosis, 
etc.).  This,  according  to  Adami,  is  a  condition  of  the  lymph  nodes 
comparable  to  keloid  in  the  skin — "an  excessive  overgrowth  of  the 
lymphoid  stroma  secondary  to  a  minimal  or  unrecognized  irritation." 
The  disease  was  referred  to  in  the  chapter  on  Tumors  (]).  114);  it 


272 


IX JURIES  AXD  DISEASES  OF  THE  LYMPHATICS 


Fig.  236.  —  Hodgkin's 
disease  affecting  the  neck 
and  both  axillae.  (Dr.  J. 
Ashhurst,  Jr.'scase.)  Uni- 
versity Hospital. 


appears  to  occupy  a  place  midway  between  the  infectious  granu- 
lomas and  pure  tumors.  Sometimes  it  resembles  tuberculosis  of 
lymph  nodes  (tuberculous  infection  may  be  secondary),  at  others  it 
approaches  lymphosarcoma  in  type.  A  number  of  observers  have 
found  in  the  affected  lymph  nodes  a  Gram-staining,  non-acid-fast, 
polymorphous  diphtheroid  bacillus. 

Symptoms. — It  afl'ects  young  adults,  especially  males,  becoming  con- 
spicuous first  in  the  neck,  as  a  diffuse,  bilateral,  hyperplastic  lymi)li- 
atic  enlargement  (Fig.  23()).  The  axillary, 
inguinal,  abdominal,  and  thoracic  nodes  are 
subsequently  affected ;  even  the  spleen  becomes 
enlarged.  The  masses  are  not  inflammatory 
in  character;  do  not  adhere  to  the  skin;  the 
individual  nodes  remain  discrete  a  long  time; 
suppuration  is  unknown;  enlargement  is  pro- 
gressiA'c,  though  temporary  remissions  may 
occur.  Severe  anemia  accompanies  the  dis- 
ease; the  patient  is  feverish,  listless,  becomes 
dyspneic,  weak,  emaciated,  and  dropsical. 
There  is  no  hyperleukocytosis,  the  only 
marked  blood  change  being  reduction  in  the 
amount  of  hemoglobin.  The  most  distressing 
symptoms  are  those  due  to  pressure  of  the 
immense  masses  in  the  neck  and  mediasti- 
num, and  it  is  for  such  effects  only  that 
surgical  treatment,  consisting  in  excision,  is  demanded.  The  disease 
tends  under  all  circumstances  to  a  fatal  termination,  the  duration  in 
most  cases  being  measured  by  months  rather  than  years.  Excision 
of  portions  of  the  mass  for  diagnosis  and  prognosis  often  is  done,  as 
the  lesions  present  a  typical  histological  picture — endothelial  pro- 
liferation, giant  and  eosinophile  cells.  Treatment  by  vaccines  made 
from  the  bacillus  mentioned  above  has  been  attempted  by  Billings 
and  Rosenow  (1913)  with  rather  encouraging  results. 

Lymphosarcoma. — Lymphosarcoma  was  referred  to  at  p.  114. 
Theoretically  we  may  distinguish  (1)  True  Lymphosarcoma,  from 
sarcomatous  proliferation  of  the  connective  tissue  cells  of  a  lymph 
node;  (2)  Malignant  Lymphoma,  from  malignant  proliferation  of 
lymphocytes  in  the  lymph  node;  and  (3)  Lymphoma  Sarcomatodes, 
indicating  secondary  (anaplastic)  sarcomatous  change  in  the  lympho- 
cytes of  a  benign  lymphoma  (p.  114).  The  distinction  is  difficult 
histologically  and  impossible  clinically. 

The  disease  may  occur  in  the  mediastinum  or  neck;  tends  to  spread 
locally,  to  ulcerate,  and  to  produce  death  by  pressure,  hemorrhage' 
or  cachexia;  internal  metastases  (liver,  lung)  may  occur  early,  due  to 
the  invasion  of  veins  by  the  original  tumor;  involvement  of  other 
groups  of  superficial  lymph  nodes  is  very  unusual. 

1  The  hemorrhagic  sloughing  ulceration  constitutes  one  form  of  the  Fungus 
nematodes  of  the  older  writers. 


WOUNDS  OF  MUSCLES  27:'. 

Diagnosis.  I  )ia^ni()sis  is  (iifficiilt:  it  nuiy  he  distiiij^uislifd  from 
Ilod^'kiii's  disease  by  tlie  rapid  growth  (weeks  rather  tluui  months), 
the  imihiteral  rather  than  hikiteral  involvement,  tlie  tendency  to 
uk'eration.  and  the  i)ersistently  kx-al  character  until  the  last  stages; 
from  fiihrrriiloyis  of  li/)iij)li  nodes  by  the  greater  firmness,  and  absence 
of  caseation  and  suppuration  even  when  ulceration  has  occurred. 
Treatment  is  of  little  avail;  excision  should  be  attempted,  especially 
to  relieve  pressure  effects;  but  complete  removal  is  difficult  and  recur- 
rence usually  is  i)romi)t. 

Carcinoma  of  Lymph  Nodes  is  secondary  to  a  primary  focus  else- 
where. So-called  primary  carcinoma  of  lymph  nodes  really  is  an 
endothelioma. 


INJURIES   AND  DISEASES  OF  MUSCLES. 

Wounds  of  Muscles  — Little  more  need  be  said  of  these  than  wiiat 
is  contained  in  the  discussion  of  wounds  in  general  (p.  105).    Sutures 

do  not  hold  very  firmly  in  mus- 
cular tissue  alone;  therefore 
mattress  sutures  are  used,  and 
in  the  case  of  transverse  division 
of  the  muscular  fibres  the  over- 
lying fascia  (muscular  sheath) 
is  included  in  the  sutures  when 
possible.  The  cicatrix  formed 
I  \         /  /        in     a     muscle    max     somewhat 


fe 


Fig.  237. — Diagram  roprfsciiting  a  ca.se  (<f 
extensive  rupture  of  the  abdomiual  wall  com- 
plicated by  fracture  of  the  iliac  crest.  The 
shaded  area  indicates  the  extent  of  the  re- 
sulting hematoma.  (See  Fig.  2.38.)  Episcopal 
Hospital. 


Fi(i.  2'.iH. — Rupture  of  abdominal 
wall  and  fracture  of  pelvis,  after  opera- 
tion. (See  Fig.  237.)  Episcopal  Hos- 
pital. 


impair  its  contractility,  but  the  disability  is  slight  unless  the  scar 
is  adherent  to  the  skin  or  bone. 
18 


274 


INJURIES  AND  DISEASES  OF  MUSCLES 


The  sheath  of  a  muscle  may  be  ruptured  by  external  injury  (con- 
tusion) or  by  violent  muscular  contraction;  the  belly  of  the  muscle, 
when  contracted,  will  then  protrude  through  the  rupture,  constituting 
a  muscular  hernia.  Some  forms  of  ventral  hernia  (Fig.  772)  are  of 
this  nature.  The  diagtiosis  is  based  on  the  history  of  trauma  and  the 
appearance  of  an  abnormal  protrusion  only  when  the  muscle  contracts; 
sometimes  when  the  muscle  is  relaxed  the  aperture  in  its  sheath  is 
palpable.  The  condition  may  be  simulated  by  an  intermuscular 
lipoma.     Treatment  consists  in  suture  of  the  rent. 

Rupture  of  a  Muscle,  much  rarer  than  rupture  of  its  tendon  (p.  278), 
usually  results  from  violent  muscular  contraction,  without  external 
injury.  The  abdominal  muscles,  however,  may  be  ruptured  sub- 
cutaneously  by  a  crushing  accident  (Fig.  237).  The  lesion  is  sub- 
cutaneous, and  when  due  to  muscular  action  alone  occurs  oftenest 
in  patients  with  rheumatic  or  fibrotic  tendencies.  When  a  long 
muscle,  such  as  the  biceps  brachii  or  quadriceps  femoris,  is  affected, 
there  is  a  distinct  hollow  perceptible  between  the  retracted  ends, 
and  this  becomes  more  evident  during  voluntary  contraction.  Func- 
tional impairment  may  be  marked. 

Treatment. — Treatment  consists  in  suture  of  the  muscle  and  its 
sheath. 

Myositis. — Myositis,  or  inflammation  of  a  muscle,  is  frequent  in 
rheumatism  and  as  the  result  of  contusions.     Septic  myositis  occurs 

by  invasion  from  a  neighboring  focus  (bone, 
joint,  lymph  node),  or  as  a  metastatic 
infection;  it  also  follows  typhoid  fever. 
In  such  cases  the  ordinary  symptoms  of 
inflammation  are  present,  and  suppura- 
tion, with  extrusion  of  sloughs  {necrotic 
masses,  p.  58),  is  the  rule.  In  traumatic 
myositis  the  muscle  becomes  swollen, 
painful,  tender,  and  of  almost  wooden 
hardness  (Fig.  239).  Suppuration  is  very 
unusual. 

Treatment. — Treatment   comprises   rest, 
i  I^^^B  S      with  application  of  sorbef acient  ointments ; 

i  ^^^^^  ■      anti-rheumatic    remedies  internally    may 

I        ^^^^^^         ■      relieve  pain.     Acupuncture  and  wet  cup- 
I     .  j^^^^^^L        ■      P^^S  ™^y  ^^  tried.     Massage  is  beneficial 

when  acute  symptoms  subside.  Meta- 
static abscesses  in  muscle  require  prompt 
evacuation. 

Myositis  Ossificans  occurs  in  two  forms, 

the  stationary  and  the  progressive. 

1.  Myositis   Ossificans  Traumatica,  the  stationary  form,  is  due   to 

injury,  usually  following  sprains,  luxations,  repeated  slight  contusions, 

etc.     If  small  fragments  of  periosteum  have  been  detached,  it  is 

possible  that  these  may  cause  bony  growth  in  the  muscles  or  tendons 


Fig.  239.— Myositis  of  left 
quadriceps  femoris;  unknown 
cause;  duration,  five  weeks. 
Aged  fifty-three  years.  Epis- 
copal Hospital. 


M  YDS  I TIS  OSSIFICA  NS 


'It  I) 


siirrouudiiit;  ;i  joint;  but  it  is  held  by  sonic  that  tlie  niusclu  ceils 
themselves  or  those  of  the  perimysium  may  produce  l)one.  The 
disease  occurs  in  the  adductor  muscle  of  the  thi^h  ("rider's  bone"), 
in  the  deltoid  from  shouldering  a  musket,  in  the  brachialis  anticus 
(Fig.  240)  following  dislocation  of  the  elbow,  in  the  tendo  Achillis 
following  sprains,  etc.  The  diagnosis  rests  on  a  history  of  injury,  and 
on  the  existence  of  a  localized,  tender,  hard,  more  or  less  movable  mass 
in  the  body  of  a  muscle  or  tendon.  The  a:-ray  usually  is  necessary 
to  confirm  the  diagnosis.  Proper  treatment  is  excision  of  the  bony 
mass,  unless  this  shows  a  tendency  to  retrogress  spontaneously  when 
the  i)art  is  ])ut  at  rest. 


Fig.  240. — Skiagraph  of  myositis  ossificans  traumatica.     New-formed  bone  in 
brachialis  anticus  muscle.    Aged  twenty-one  years.    Episcopal  Hospital. 


2.  Myositis  Ossificans  Progressiva  is  an  obscure  affection,  perhaps 
due  to  auto-intoxication,  l^eginning  in  the  first  ten  years  of  life  and 
progressing  slowly  "with  intervals  of  quiet,  death  occurring  in  ten 
or  twelve  years — either  from  some  intercurrent  disease,  especially 
bronchopneumonia,  or  from  inanition  due  to  involvement  of  the 
masseter  muscles."  (W.  Walker,  1908.)  The  thumbs  and  great  toes 
usually  have  a  congenital  deformity  {microdactylia)  consisting  in 
shortening  of  the  metacarpal  or  metatarsal  bones,  sometimes  with 
ankylosis  of  the  phalanges  (Fig.  241).  The  muscles  oftenest  affected 
are  in  the  trunk,  the  upper  extremity,  and  the  neck,  especially  tlie  tra- 


276 


I. \J CRIES   AXD   DISEASES  OF  MISCLES 


pezius,  latissimiis  dorsi,  sterno-mastoid,  and  shoulder  muscles  (Vi^.  242) . 

The  disease  betrins  with  soreness  and  stiffness  in  the  affected  muscles, 

attended  by  local  cyanosis  and  doughi- 
ness.  After  weeks  or  months  another 
exacerbation  occurs,  and  finally  bony 
masses  become  palpa})le  and  demon- 
strable by  the  .r-ray.  No  treatment 
has  been  of  any  avail. 

Contractures  of  Muscles  resulting 
ill  limitation  of  articular  motion  (false 
ankylosis),  follow  rheumatic,  gouty, 
or  other  inflammations,  but  are  of 
special  interest  to  surgeons  in  cases 
of  infantile  palsy  or  patients  with 
bone  and  joint  disease.  ^Yeight  ex- 
tension, the  use  of  a  Stromeyer  splint, 
elastic  traction,  massage,  passive 
motion,  etc.,  sometimes  are  efficient 
in  overcoming  the  deformtiy.  but  not 
infrequently  mobilization  under  anes- 
thesia, or  myotomy  and  tenotomy  are 

required.     If  the  joint  capsule  is  the  seat  of  contracture  it  may  have 

to  be  incised  also.     CSee  Figs.  243  and  244.) 


Fig.  241.  —  Microdactylia  in  a 
case  of  myositis  ossificans  progres- 
siva. (Dr.  Warren  Walker's  case.) 
Children's  Hospital. 


Fig.  242 


-Myositis  ossificans  pnjgressiva  showing  deposits  in  muscles  of  back. 
(Dr.  Warren  Walker's  case.)    Children's  Hospital. 


Ischemic  Contracture  (see  p.  540). 

Trichiniasis. — Ingestion  of  the  embryos  of  trichina  spiralis,  a 
parasite  infesting  uncooked  pork,  is  followed  by  their  migration  to 
and  development  in  the  muscular  tissues.  Within  a  week  or  ten 
days  after  eating  the  contaminated  food,  the  patient  is  attacked 
with  muscular  soreness,  widely  distributed,  which  frequently  is 
regarded  as  rheumatic.  Diarrhea  often  is  present,  and  fever  is  usual. 
Examination  of  the  blood  shows  eosinophilia   (even  as  high  as  50 


WOUNDS  OF  TENDONS  277 

per  cent.).  Microscopical  exuiiiiiiatioii  of  excised  imisciilar  tissue 
confirms  the  diaj^nosis.  Beyond  purgation,  treatment  is  of  little 
value;  and  the  duration  of  the  disease  appears  to  be  self  limited 
to  a  few  weeks. 


I.F1G.  243. — Contractures  of  ilio-psoas  muscles  following  neglected  case  of  Pott's 
disease  of  spine.    Children's  Hospital. 

Tumors  of  Muscles. — Rhabdomyoma  and  leiomyoma  have  been 
discussed  at  p.  114.  Desmoids  are  tumors  growing  from  muscle  or 
fascia,  usually  of  the  abdominal  wall,  analogous  to  keloids  in  the 


Fig.  244. — Contractures  of  feet,  following  paralysis  of  extensor  muscles  from  fracture 
of  tenth  and  eleventh  thoracic  vertebrse,  five  years  previously.    Episcopal  Hospital. 

skin.  They  usually  are  single,  oftenest  arise  after  pregnancy  or  in 
an  operative  cicatrix,  and  sometimes  recur  after  extirpation,  assuming 
sarcomatous  characteristics. 


INJURIES  AND  DISEASES  OF  TENDONS. 

Wounds  of  Tendons. — Wounds  of  tendons  are  of  frequent  occur- 
rence, and  often  are  followed  by  marked  disability,  owing  to  adhesion 
of  the  tendons  to  their  sheaths,  to  each  other,  to  the  skin,  to  bone, 
etc.,  even  if  careful  primary  suture  has  been  done.  Tendons  retract 
when  divided,  and  the  surgeon  must  not  hesitate  to  enlarge  the 
original  wound  to  find  the  divided  ends.  Usually  it  is  better  to 
administer  a  general  anesthetic,  especially  in  wounds  of  the  flexor 
tendons  above  the  wrist.  ]\Iattress  sutures  are  preferable,  and  if  the 
ends  cannot  be  made  to  meet,  tendon  lengthening  may  be  emploved 
(Fig.  2G4). 


278 


INJURIES  AND  DISEASES  OF  TENDONS 


Subcutaneous  Rupture  of  Tendons  is  more  frequent  than  that  of 
their  muscidar  l)ellies.  Usually  it  occurs  only  in  already  slightly 
diseased  tissues,  especially  in  cases  of  periarthritis  (p.  4()()),  dystrophic 
arthritis,  etc.  Following  a  sudden  strain,  the  patient  is  conscious 
of   something    giving    way,   perhaps    with   an   audihle   snap;   severe 


Fig.  245. — Rupture  of  long  head  of  biceps  brachii,  forty-eight  hours  after  accident, 
from  violent  contraction  while  leading  unruly  horse  by  halter.  Dr.  G.  G.  Davis's 
case.     Orthopaedic  Hospital. 

stinging  pain  occurs,  and  the  part  is  disabled.  Ecchymosis  appears 
subsequently,  and  when  the  affected  muscle  is  voluntarily  contracted, 
a  characteristic  deformity  is  seen,  owing  to  the  loss  of  attachment 
of  the  tendon.  The  biceps  brachii,  especially  its  long  scapular  head, 
(Fig.  245),  and  the  quadriceps  femoris  are  often  affected;  rupture  of 
one  of  the  tendons  of  the  extensor  longus 
digitorum  near  its  insertion  in  the  finger 
is  not  unusual  (Fig.  24(i).  So-called  rup- 
ture of  the  plantaris  probably  is  not 
as  frequent  as  supposed  (p.  243).  In 
the  phalanges,  firm  bandaging  on  a 
splint  for  several  weeks  may  prevent 
permanent  deformity  or  disability;  in 
other  cases  the  affected  tendon  should 
be  sutured. 


Fig.  246. — Rui>turp  of  tendon  of  extensor 
longus  digitorum  to  fifth  finger;  from  fall  on 
hand  two  months  ago.    Episcopal  Hospital. 


Fig.  247. — Luxation  of  pero- 
neal tendons  in  front  of  external 
malleolus  of  left  foot,  following 
paralytic  calcaneus.  Orthopaedic 
Hosjjital. 


Dislocation  of  Tendons  may  be  pathological  or  traumatic.  The 
former  is  more  frequent,  and  is  secondary  to  changes  in  the  contour 
of  the  neighboring  joints,  or  to  peri-arthritic  lesions  causing  obliter- 


I'MiONVdllA    OR   PANARIS  270 

atioii  ol"  llic  iiMtural  tiTooxc  in  wliicli  tlic  tendon  lies.  In  ciises  of 
int'iintilc  ]);iriil\sis  witli  marked  caleani'iis  detoriiiity  the  pcroncdl 
t('ii(lu)is  may  hv  luxated  anterior  to  the  external  malleolus  (Fi^-  247); 
in  i-ases  of  knock-knee  or  sim])le  relaxation  of  tissues  around  the  knee- 
joint,  oiifirard  lu.vdfloii  of  the  jxifflla  may  occur;  in  peri-artiiritis  of 
the  shoulder,  iiiirdnl  dislocation  of  flic  long  head  of  the  biceps  sometimes 
is  seen,  allowinj;-  a  subluxation  forward  of  the  head  of  the  humerus. 
These  deformities  may  he  remedied  by  ojxTation  if  disability  is 
marked.  Correction  of  any  i)rcdis])()sint:;  deformity  is  the  first  step. 
In  the  case  of  the  patella  a  suitable  knee-caj)  may  give  relief,  or  the 
inner  portion  of  the  capsule  may  be  pleated  on  itself,  or  the  point 
of  insertion  of  the  tendo  patelhe  may  })e  shifted  inward.  The  capsule 
of  the  shoulder  may  be  })leated,  and  the  biceps  tendon  shortened. 

Strains  of  Tendons  are  of  frequent  occurrence.  Minute  extrava- 
sations occur  among  the  rujjtured  fibres,  and  the  tendon  is  swollen, 
painful,  and  tender.  Schanz  (1005)  has  called  particular  attention  to 
traumatic  inflanmiation  of  the  tendo  Achillis,  which  often  is  mistaken 
for  achillodynia  (p.  207).  Some  cases  of  "trigger  finger"  (p.  543) 
may  have  a  similar  origin.  The  treatment  is  rest  during  the  acute 
stage,  followed  by  massage. 

Tenosynovitis  or  Thecitis  is  the  name  given  to  a  form  of  inflam- 
mation of  tendon  sheaths  usually  caused  by  rejjeated  trauma  (strains), 
in  those  predisposed  to  rheumatic  conditions.  It  occurs  oftenest 
in  the  extensor  tendons  at  the  wrist,  but  is  also  seen  at  the  ankle, 
and  elsewhere.  There  is  a  fine  crackling  and  creaking,  appreciable 
on  palpation  and  sometimes  audible,  whenever  the  affected  tendons 
are  moved;  this  is  caused  by  effusion  of  plastic  lymph  between  the 
tendon  and  its  sheath.  The  disease  never  progresses  to  the  stage 
of  suppuration. 

Treatment. — Treatment  consists  in  splinting  the  part  and  applying 
ointments  of  ichthyol  or  of  belladonna  and  mercury,  iodin,  etc. 
Local  rest  should  be  insisted  on  until  physical  signs  have  been  absent 
for  a  week  at  least;  otherwise  recurrence  is  usual.  With  prompt 
treatment  work  generally  may  be  resumed  in  a  few  weeks. 

Tuberculosis  of  Tendon  Sheaths  usually  is  secondary  to  tuber- 
culous synovitis  or  arthritis  (p.  477).  See  also  Tuberculous  Ganglion, 
p.  281.' 

Paronychia  or  Panaris. — This  is  a  rather  vague  term,  denoting 
a  septic  inflammation  about  the  flexor  surface  of  the  finger  tips 
(very  rarely  of  the  toes).  (1)  Digital  Abscess:  The  mildest  form  is 
an  abscess  in  the  pulp  of  the  finger,  not  involving  tendon  or  bone. 
Incision  in  the  long  axis  of  the  finger  evacuates  the  pus  and  leads  to 
rapid  healing.  (2)  If  the  tendon  sheath  is  involved  the  affection  is 
known  as  ivhitloiv.  In  the  thumb  and  fifth  finger  such  inflammation 
(arising  from  a  pin  prick,  abrasion,  hangnail,  run-around  (p.  260), 
etc.),  may  spread  readily  to  the  palmar  bursa,  with  which  the  sheaths 
of  these  tendons  usually  are  continuous,  forming  jKilmar  abscess 
(Fig.  248).    The  finger  tip  becomes  extremely  painful,  tender,  throb- 


2Rn 


INJURIES  AMD  Dh'^EAMm  OF  TENDONS 


bing,  and  swollen.  The  patient  speilcb  a  sleepless  night;  poultices 
bring  little  relief;  inflammation  spreads  up  the  tendon  sheath,  and 
the  whole  finger  is  swollen  to  two  or  three  times  its  natural  size. 
Occasionally  a  whitlow  will  evacuate  itself  if  ])oulticed  long  enough 
(Fig.  241)),  but  proper  treatment  consists  in  very  early  free  incision, 


Fig.  248. — Palmar  abscess ;  duration, 
one  week;  showing  ineffectual  incisions 
made  three  days  ago.  Episcopal  Hos- 
pital. 


Fig.  249. — Whitlow;  spontaneous  rup- 
ture; duration,  eleven  days;  untreated. 
Children's  Hospital. 


into  the  tendon  sheath,  and  the  application  of  hot  moist  antiseptic 
dressings,  with  suitable  splint  and  sling.  At  later  stages  local  or 
general  anesthesia  may  be  necessary,  with  numerous  counter-openings 
and  tube  drainage,  or  antiseptic  irrigation.  After  proper  incisions,  the 
continuous  bath  is  especially  useful.  Only  when  incision  is  done  at 
the  earliest  stage  can  sloughing  of  the  tendon  be  prevented:  the 
tendon  receives  its  vascular  supply  through 
delicate  reflections  of  the  synovia,  and  very 
slight  swelling  within  the  tendon  sheath 
is  sufficient  to  obliterate  this  circulation. 
If  the  tendon  sloughs  the  incision  will  be 


Fig.  2.51. — Bilocular  ganglion 
Fig.  250. — Ganglion  on  extensor  surface  of  wrist   (see       excised  from    wrist    (see    Fig. 
Fig.  251).     Episcopal  Hospital.  250).    Episcopal  Hospital. 


slow  in  healing,  and  a  stiff  finger  will  result.  Healing  of  a  chronic 
sinus  sometimes  may  be  hastened  by  dressing  it  with  mercurial 
ointment.  (3)  If  the  periosteum  or  phalanx  is  involved,  the  disease 
is  known  as  a  bone  felon,  but  as  the  distinction  from  whitlow  rarely 
can  be  made  before  incision,  and  as  treatment  is  the  same,  there 


a  A  NO  LI  ON 


2X1 


Is  little   use  in   niakiiifj;  a  separate  sui)(li\isi()ii   for  felons.     Excision 
or  am])utatioii  may  he  necessary  it"  the  i)lialan\  heconies  necrotic. 


Fic.   2.")2. — Tuberculous  ganglion  of  right  wrist  and  palm  (hour-glass  swelling). 
Aged  forty-two  years;  duration,  five  years.     Orthoptedie  Hos|)ital. 


Ganglion. — A  ganglion  is  a  cyst  developed  in  connection  with  a 
tendon  sheath,  or  from  the  snbsynovial  tissues  of  a  joint  capsule.  Its 
pathogenesis  is  not  well  understood,  but 
probably  is  a  degenerative  change  (Clarke, 
1908).  Frequently  slight  trauma  has 
occurred,  but  often  no  such  history  can 
be  obtained.  Ganglia  occur  oftenest  in 
women,  being  especially  frequent  on  the 
extensor  surface  of  the  wrist  (Fig.  250) ; 
they  are  seen  less  often  at  the  ankle  or 
in  the  palm  of  the  hand  (Fig.  252)  and 
certain  bursal  enlargements  seem  clini- 
cally identical  with  ganglia  (Figs.  230 
and  253).  Occasionally  a  ganglion  con- 
tains rice-like  bodies,  similar  to  "joint- 
mice"  (p.  478);  and  sometimes  a  gan- 
glion is  frankly  tuberculous;  this  is 
especially  apt  to  be  the  case  in  "com- 
pound ganglia,"  where  the  cystic  mass 
is  more  or  less  lobulated,  possibly  as 
the  result  of  the  coalescence  of  several 
distinct  ganglia. 

Treatment. — If  operative  treatment  is 
refused,  a  small  ganglion  may  be  dis- 
persed by  a  smart  blow  with  a  heavy 
book,  the  part  being  splinted  subse- 
quently for  a  week  or  so;  recurrences 
may  be  expected  in  over  half  the  cases 
so  treated.     Safer  and  better  treatment 

is  aspiration  and  injection  of  2  per  cent,  formalin  glycerin  solution  or 
of  dilute  iodin  or  alcohol;  or  formal  excision  of  the  ganglion.  Tuber- 
culous ganglia  never  should  be  treated  by  attempts  at  rupture. 


Fig.  25.3. — Ganglia  in  popliteal 
space;  aged  eighteen  years;  dura- 
tion, over  one  year.  Episcopal 
Hospital. 


282 


INJURIES  AND  DISEASES  OF  NERVES 


INJURIES  AND  DISEASES  OF  NERVES. 

Contusion. — Contusion  of  a  nerve  produces  tingling  and  perhaps 
numbness  or  paralysis  in  its  distribution.  A  frequent  lesion  is  i)aralysis 
of  the  musculo-spiral  nerve  (less  often  of  the  circumflex)  from  pressure 


Fig.  254. — Paralysis  of  musculo-spiral  nerve  from  overlying. 


during  sleep  (overlying) — most  seen  after  a  debauch,  the  patient  having 
lain  stuporous  for  many  hours  (Fig.  254).    In  other  cases  the  lesion 

results  from  a  sudden  blow  or  fall, 
perhaps  from  sudden  abduction 
of  the  humerus  (Fig.  255). 
Cridrh-pdlsy,  affecting  the  axil- 
lary nerves,  especially  the  mus- 
culo-spiral, is  caused  by  the 
patient  bearing  most  of  his  weight 
on  the  axilla  instead  of  on  his 
hands,  usually  because  the  hand- 
bars  of  the  crutches  are  placed  too 
low.  Post-anesthetic  palsy  is  due 
to  direct  pressure,  the  arm  hav- 
ing been  allowed  to  hang  over  the 
edge  of  the  table  (musculo-spiral, 
ulnar) ;  or  from  pressure  on  the 
peroneal  nerve  below  the  head  of 
the  fibula.  This  latter  form  of 
paralysis  may  result  from  im- 
proper application  of  a  gypsum 
case.  As  a  rule,  the  only  treat- 
ment required  is  rest,  followed  by 
massage,  electricity,  etc.  Subcu- 
taneous rupture  is  extremely  rare, 
but  in  compound  fractures  or 
similar  accidents  a  nerve  may  be 
crushed,  complete  destruction  of  the  nerve  fibres  occurring,  and  only  the 
sheath  remaining  to  connect  the  bruised  ends  of  the  nerve.  The  signs 
of  loss  of  function  due  to  such  nerve  injuries  usually  are  subordinate 


Fig.  2.5.5. — Paral.wsis  of  left  circumflex 
nerve  with  atrophy  of  deltoid  muscle, 
from  sprain  of  shoulder  five  months  ago. 
Patient,  aged  sixty  years,  fell  twenty-seven 
feet.     Episcopal  Hospital. 


STRETCHING  OR  I.ACER ATION 


2S3 


to  tliosr  due  to  tlie  lesions  of  the  iiuisolos,  tendons,  and  bones;  l)ut  in 
all  snch  accidents  the  surfjeon  shonld  make  tests  lor  sensation  and 
motion  in  tli(>  i)ait  supplied  by  any  nerves  which  possibly  might  have 
been  injured.  Kesection  of  the  dania<;-ed  jjortion,  with  end-to-end 
union  of  the  nerve  stumps  should  be  done,  as  described  under  WOiutd.s 
of  Nrnr.s'  (p.  2X1). 

Dislocation. — Dislocation  of  a  nerve  is  rare.  Occasionally  the 
ulnar  nerve  slii)s  in  front  of  the  internal  condyle,  and  causes  moderate 
disability.  OptTation  generally  is  necessary  to  replace  such  nerves 
and  consists  in  restoring  normal  relations  and  suturing  a  layer  of 
fascia  over  the  nerve  to  hold  it  in  place. 

Stretching  or  Laceration. — Stretching  or  laceration  of  nerves  is 
not  iufrccpient  as  a  subcutaneous  injury  In  dislocations  or  sprains 
of  the  shoulder  the  circumflex,  and  more  rarely  the  musculo-spiral 
nerve,  may  thus  be  damaged;  or 
rarely  the  cords  of  the  brachial 
plexus  may  be  injured.  (See  also 
Neuritis,  p.  287,  and  Periarthritis, 
p.  4()6.)  According  to  Vanden- 
bossche  (1910)  it  is  probable  that  in 
most  of  these  latter  cases  the  lesion 
is  in  the  nerve  roots  rather  than  in 
the  brachial  plexus.  Duval  and 
Guillain  (1898)  maintained  that 
there  were  no  such  clinical  entities 
as  paralyses  due  to  lesions  of  the 
plexus,  only  two  types  existing, 
radicular  and  terminal,  affecting 
either  the  spinal  motor  roots  or 
the  nerve  trunks  below  the  plexus. 
The  usual  cause  of  obstetrical 
palsy  (brachial  birth  palsy)  is  either 
direct  pressure  on  the  plexus  by 
forceps  in  delivery  (rare),  or  stretch- 
ing and  laceration  from  attempts  to  deliver  a  shoulder  by  injudicious 
traction  on  the  head,  or  in  delivery  of  the  after-coming  head.  The 
usual  deformity  is  characteristic  (Fig.  256),  due  to  paralysis  of  the 
external  rotator  muscles;  the  hand  is  little  affected,  but  supination  and 
flexion  of  the  forearm  are  imperfect  or  entirely  absent.  This  corre- 
sponds to  the  "upper  arm"  type  (Duchenne-Erb)  of  brachial  paralysis, 
the  lesion  being  in  the  outer  cord  (i.  e.,  fifth  and  sixth  cervical  nerves) 
of  the  brachial  plexus,  involving  especially  the  suprascapular  and  mus- 
culo-cutaneous  nerves  (Fig.  G36).  The  "  lower  arm"  type  and  paralysis 
of  the  entire  extremity  are  rare.  T.  T.  Thomas  (1914)  contends  that  in 
most  of  these  cases  the  nerve  injurj^  is  secondary  to  joint  damage,  and 
that  treatment  of  the  latter  is  the  main  indication  (see  also  Congenital 
Dislocation  of  the  Shoulder,  p.  513).  In  brachial  palsy  the  prog- 
nosis is  not  very  good,  some  disability  usually  persisting  throughout 


Fig.  256.— Braohial  birth  i>alsy  f)f 
the  left  arm.  in  a  boy  aged  seventeen 
months.  Typical  posture.  Ortho- 
psedic  Hospital. 


284  INJURIES  AND  DISEASES  OF  NERVES 

life,  no  matter  what  the  treatment.  Rupture  of  the  nerve  sheaths 
occurs  first,  and  there  is  more  or  less  laceration  of  the  nerve  fibres 
themselves;  intra-  and  peri-neural  hemorrhage  occurs,  with  marked 
cicatricial  changes  in  the  plexus  and  overlying  cervical  fascia.  Trraf- 
mctit.  After  a  period  of  rest,  until  acute  symptoms  subside,  strychnin 
should  be  administered,  and  efforts  made  to  improve  the  nutrition 
of  the  muscles  by  massage,  electricity,  baths,  etc.  Should  no  further 
improvement  occur  in  six  months  or  a  year,  operation  must  be  con- 
sidered. A.  S.  Taylor  (1913)  urges  exploratory  operation  as  soon 
after  birth  as  the  general  condition  of  the  infant  warrants;  but  his 
results  do  not  encourage  imitation  when  it  is  remembered  what  great 
improvement  usually  follows  conservative  treatment.  After  exposing 
the  plexus,  it  is  dissected  free  from  the  cicatricial  adhesions,  irre- 
trievably damaged  segments  of  nerve  tissue  are  excised,  and  the 
stumps  reunited  or  implanted  into  another  nerve  as  described  below 
(p.  286).  Alexinsky  (1899)  proposed  transplanting  the  peripheral  ends 
of  the  damaged  nerve  roots  to  the  opposite  side  of  the  neck,  and 
uniting  them  to  the  central  ends  on  the  other  side;  a  similar  operation 
has  been  done  by  Babcock  (1907),  in  a  case  of  anterior  poliomyelitis. 
^Muscle  and  tendon  transplantation  often  will  give  better  results  than 
any  operations  on  the  nerves. 

Wounds  of  Nerves. — These  may  be  an  incident  in  extensive  lacerated 
wounds  in\'olving    muscles,    tendons,  and    bloodvessels;,  or    isolated 

injuries  due  to  stab  wounds  (Fig.  257). 
The  symptoms  are  complete  loss  of  func- 
tion in  the  distribution  of  the  injured 
nerve;  usually  this  implies  loss  of  both 
motion  and  sensation.  If  only  a  per- 
ipheral sensory  nerve  is  divided,  sensation 
may  return  in  time,  even  if  the  ends  of 
the  nerve  are  not  sutured;  this  is  due  in 
part  to  regeneration,  and  in  part  to  col- 
lateral circulation,  as  it  were,  in  surround- 
ing nerve  filaments.     But  unless  the  ends 

I'iG.   2.57. — Paralvsis  of  pero-  p  ,  i  i  j.   •    x 

neai  nerve  following  injury  of     ot  a  motor  ucrvc  are  brought  mto  accu- 

cauda  equina  in  spinal  anes-  rate  apposition  bv  SuturC,  paralvsis  of 
thesia;  seventeen  months  dura-  •  -n   i  '  ^         \  iv       "     j. 

tion.   Orthopcedic  Hospital.  motion  Will  be  permanent.     Alter  suture, 

the  prognosis  is  uncertain,  though  if  suture 
is  done  soon  after  the  accident  {primary  suture)  more  or  less  com- 
plete recovery  is  the  rule  (Figs.  258  and  259);  after  secondary  suture 
the  results  are  very  uncertain  (Figs.  260  and  261). 

Howell  (1892)  collected  84  cases  of  primary  nerve  suture,  with 
42  per  cent,  successful  results,  and  40  per  cent,  improved;  and  80 
cases  of  secondary  suture,  with  38  per  cent,  successful,  and  50  per 
cent,  improved. 

Treatment. — The  nerve  should  be  exposed,  and  all  damaged  tissue 
excised  with  a  sharp  knife.  The  cicatricial  tissue  must  be  excised  until 
the  projecting  ends  of  the  nerve  fibres  can  be  seen  in  the  cross-section. 


WOUNDS  OF  NERVES 


285 


Scissors  bruise  nervos,  and  never  should  he  use<h     The  ends  arc  then 
united  (neurorrhaphy)  with  ver\'  fine  silk  or  elironiie  catjiut  threaded 


Fig.  25S>. — Kccovcij-  after  primary  suture  of  lausculospiral  nerve,  for  stab 
wound.    Episcopal  Hospital. 

in  ophthahnic  needles.    The  sutures,  some  of  which  should  be  of  the 
mattress  type,  pass  directly  through  the  nerve,  and  are  tied  just 


Fiii.   259. — Recovery  of  function  after  primary  suture  of  musculospiral  nerve 
for  stab  wound.    Episcopal  Hospital. 

tight  enough  to  approximate  without  constricting  the  ends;  a  few 
guy  sutures  should  then  be  applied  merely  through  the  nerve  sheath, 


Fig.  260. — Stab  wound  of  median  nerve  just  after  operation  of  secondary  suture 
(three  months  after  injury) ;  showing  inability  to  flex  wrist,  index  finger,  and  thumb 
(see  Fig.  261).     (Dr.  Harte's  case.)     Orthopaedic  Hospital. 

to  relieve  strain,  and  prevent  adhesions  of  the  nerve  fibres  to  surround- 
ing structures  (Fig.  262).  If  for  any  reason,  the  ends  of  the  nerves 
cannot  be  made  to  meet  (even  by  nerve-stretching  and  flexing  neighbor- 


286 


INJURIES  AND  DISEASES  OF  NERVES 


ing  joints),  both  ends  may  be  implanted  into  a  neighboring  nerve  trunk 
(nerpe  anastomosis)  (Fig.  203),  or  neuroplasty  may  be  done  (Fig.  2(54). 
A  layer  of  muscle  should  then  be 
sutured  over  the  nerve,  to  prevent 
adhesion  to  the  skin;  the  wound 
should  be  closed;  and  the  limb  kept 
at  rest  for  two  or  three  weeks,  when 
light  massage,  electro-therapy,  etc., 


Fig.  261.  —  Recovery  of  function  eight 
months  after  secondary  suture  of  median 
nerve  (see  Fig.  260).  Note  power  of  flexing 
wrist,  index  finger,  and  thumb.  (Dr. 
Harte's  case.)     Orthopaedic  Hospital. 


Fig.  262.  —  Nerve  suture.  Two 
mattress  sutures  have  been  inserted, 
passing  into  the  nerve  substance,  and 
two  sutures  including  only  the  sheath. 


may  be  commenced.   Sensation  returns  long  before  motion,  sometimes 
within  a  few  days;  but  hope  of  motion  should  not  be  abandoned 


\;j5^v; 


Fig.  263. — Nerve  anastomosis.      A,  the  distal  Fig.  264.  —  Neuroplasty.      The 

segment  of  the  wounded    nerve  is  sutured  into  a  proximal  segment  is  split  and  a  flap 

slit  in  a  neighboring  nerve;  B,  it  is  implanted  in  is  turned  down  and  sutured  to  the 

a  wedge-shaped  incision.  distal  segment. 


NEURITIS  287 

for  about  a  year  after  suture,  unless,  of  course,  it  can  be  sliown 
that  the  sutures  have  given  way.  Under  such  circumstances  the 
ojxTation  may  be  clone  over  ajjain.  In  all  cases  development  of 
deformity  must  be  prevented  by  splints,  braces,  passive  motion, 
etc.  Regeneration  of  sutured  nerves  dej)ends  on  the  formation  of  new 
axones,  which  some  hold  develop  from  proliferation  of  neurilemma 
cells  in  the  peripheral  segment,  while  others  maintain  that  in  all 
cases  the  axones  grow  out  from  the  central  segment,  and  have  to 
penetrate  the  distal  segment  to  its  various  terminations  before  function 
is  restored.  At  present  the  weight  of  evidence  appears  to  be  in  favor 
of  those  upholding  the  former  view  (Ballance  and  Stewart,  1901), 
and  it  is  this  teaching  which  justifies  us  in  urging  late  secondary 
suture;  the  axone  is  there,  merely  waiting  to  be  joined  to  the  cen- 
tral segment.  So  long  as  the  muscles  have  not  become  hopelessly 
degenerated,  nerve  suture  may  be  successful  (after  fourteen  years, 
Jacobson).  Nerves  which  have  no  neurilemma  do  not  regenerate; 
the  nerves  of  special  sense  have  no  neurilemma;  nor  have  the  soinal 
nerves  except  peripheral  to  the  spinal  ganglia. 

Neuritis. — Neuritis,  as  the  term  usually  is  understood,  implies 
not  a  reaction  to  septic  infection,  but  a  form  of  subacute  or  chronic 
inflammation  due  to  contusion,  to  pressure  (from  cicatrices,  callus, 
exostoses,  tumors,  etc.),  to  recurrent  trauma  {occupation  neuritis),  to 
toxic  infections  (influenza,  typhoid  fever,  etc.),  intoxicants  (alcohol, 
lead,  etc.),  and  other  less  well  defined  causes.  The  pathological 
change  is  proliferation  of  the  nerve  sheath  (epineurium,  perineurium, 
and  endoneurium),  which  compresses  the  nerve  fibres  (axones),  leading 
to  pain,  impairment  of  function,  and  various  trophic -disturbances  in 
the  distribution  of  the  affected  nerve.  The  nerve  trunk  is  hj-peremic, 
perhaps  edematous,  swollen,  and  bulbous.  Perineural  adhesions  are 
frequently  present. 

Symptoms. — The  onset  may  be  sudden,  after  exposure  to  cold, 
after  violent  exertions,  or  any  factor  which  reduces  the  patient's 
vitality.  Pain  is  present  in  the  portion  of  the  nerve  diseased,  and 
also  shoots  along  the  course  of  this  nerve,  usually  in  a  peripheral 
but  sometimes  in  a  central  direction.  There  is  tenderness  along 
the  course  of  the  nerve,  and  cutaneous  hyperesthesia  may  be  very 
marked;  numbness  and  a  sense  of  swelling  (vaso-motor  or  trophic 
disturbances)  may  be  present  in  the  area  of  distribution.  The  skin 
becomes  glossy,  appears  tense  and  hyperemic;  sweating  usually  is 
diminished;  incurvation  or  shedding  of  the  nails  may  occur  (Fig.  2(j5); 
the  muscles  become  atrophic  and  contractures  and  reactions  of 
degeneration  may  develop. 

The  nerve  trunks  most  often  affected  are  those  of  the  brachial 
plexus,  the  musculo-spiral,  ulnar,  and  median,  and  the  sciatic.  It 
must  be  remembered  that  the  neuritis  may  be  only  a  symptom  of 
another  affection  (periarthritis  of  -the  shoulder,  p.  466;  ischemic 
contracture,  p.  540;  sacro-iliac  or  hip-joint  disease,  p.  536;  etc.). 


288 


INJURIES  AND  DISEASES  OF  NERVES 


Treatment.— Treatment  comprises,  first  and  foremost,  removal 
of  the  cause,  whenever  this  can  be  discovered  (calhis,  tumor,  cicatrix, 
etc.).  In  all  cases  rest  is  of  utmost  importance,  and  should  always 
be  the  first  step  when  no  obvious  cause  exists.  Counter-irritation 
sometimes  is  of  value.  The  patient's  general  health  should  be  im- 
proved. Antiseptics  may  be  administered  internally,  especially  the 
salicylates.  Electro-therapeusis,  massage,  and  baking,  are  suitable 
only' for  the  chronic  stages,  after  rest  has  allayed  the  acuter  symp- 
toms. In  many  cases  operation  is  of  benefit  (Fig.  2fifi),  especially 
neurolysis  (dissection  of  the  nerve  trunk  and  even  dissociation  of  its 
fibres) ;  neurectasy  (nerve-stretching)  is  a  less  certain  operation,  though 
aiming  to  accomplish  the  same  results;  neurotomy  and  neurectomy 
(except  when  purely  sensory  branches  are  involved)  seldom  are  justi- 
fiable until  other  operations  have  failed. 


F„,     onr.  _photo"-niijh    showing  Fig.  26G.— Photogriiph    lundv    ciKlit   weeks 

tnS;!^;  ;h^n.S^g!>i\>ails  as  t  after  operation,     to    show    !^-ven.n^  m 

result  of  neuritis  of  median  nerve.  finger     nails.       (bee    tig.     2b5.)       i^pibcopai 

January  31,   1907.     Episcopal  Hos-  Hospital, 
jjital. 

Neuralgia.— Neuralgia,  signifying  pain  in  a  nerve  for  which  no 
pathological  lesion  can  be  held  accountable,  remains  an  inscrutable 
problem;  and  to  state,  as  is  often  done,  that  such  changes  as  may 
be  found  on  microscopical  examination  of  the  affected  nerve  are 
the  result,  not  the  cause  of  the  disease,  in  no  way  renders  the  subject 
easier  to  understand.    In  a  word,  neuralgia  is  held  to  be  a  tunctional 


XKLh'ALClA    OF   Till':   l-lFTll   CJi'AMAL   SKl{VI<:  L^S•) 

neurosis.  Many  cases  of  sii])iif)S('(l  neuralgia,  however,  will  he  foniid 
oil  careful  iuvestij^atiou  to  he  due  to  referred  jxi'ni  from  definite  lesions 
elsewhere.     Many  are  reallx'  cases  of  neuritis. 

Symptoms. — Its  symptoms  differ  somewhat  from  those  of  neuritis; 
tlie  ])ain  is  equally  great,  but  may  come  and  ^o  without  api)arent 
cause;  it  is  more  l)urnin<:;  and  achinji;  than  sharp  and  shooting  in 
character;  is  more  influenced  hy  damj)  weather  and  exposure  to  cold; 
and  may  he  unattended  with  actual  changes  in  the  overlying  tissues, 
which  are  common  in  neuritis.  The  tenderness  does  not  extend  over 
the  entire  course  of  the  afi'ected  nerve,  but  is  most  intense  at  certain 
jioints  ("])oints  douloureux,")  especially  where  the  nerve  passes 
through  a  foramen  (intervertebral,  supra-orbital,  mental,  etc.),  or 
through  the  deep  fa.scia;  and  pressure  on  the  nerve  with  the  palm  of 
the  hand  relieves  rather  than  aggravates  the  pain,  though  pressure 
by  the  finger  tip  or  pointed  instrument  may  bring  on  an  exacerbation 
of  pain. 

Treatment. — Treatment  is  much  the  same  as  for  neuritis,  which 
often  can  be  excluded  from  the  diagnosis  only  after  prolonged  rest 
has  failed  to  give  relief.  Injections  of  cocain,  alcohol,  osmic  acid 
(1  per  cent.),  and  other  substances  into  or  around  the  nerve  have 
been  adopted  in  many  cases  with  varying  results  (p.  290).  Neu- 
rectasis, neurolysis,  and  even  neurotomy  and  neurectomy  may  be 
done. 

The  forms  of  neuralgia  most  important  to  the  surgeon  are: 
Neuralgia  of  the  fifth  cranial  nerve;  Brachial  Neuralgia  (which  has 
been  sufficiently  discussed  under  the  heading  Neuritis) ;  and  Sciatic 
Neuralgia. 

Neuralgia  of  the  Fifth  Cranial  Nerve;  Tri-Facial  Neuralgia  or  Tic 
Douloureux. — The  pathology  of  this  affection  is  very  little  under- 
stood. Two  types  are  recognized:  the  minor  neuralgia,  and  the  major 
or  epileptiform  neuralgia.  In  the  former,  which  probably  is  a  true 
neuralgia,  there  is  more  or  less  continuous  pain,  but  it  is  not  exces- 
sively severe;  usually  some  local  or  constitutional  cause  can  be  found, 
and  on  remedying  this  the  neuralgia  may  stop  for  a  time  or  permanently. 
Among  such  causes  are  caries  of  the  teeth,  sinus  diseases,  malaria,  lead 
poisoning,  chronic  nephritis,  gout,  etc.  The  major  neuralgias,  on 
the  contrary,  appear  to  be  due  to  some  central  lesion  which  involves 
the  Gasserian  ganglion  either  primarily  or  by  extension  from  disease 
of  its  branches,  or  possibly  by  pressure  from  some  intracranial  growth. 
This  form  of  the  disease  is  characterized  by  progressively  severer 
attacks  of  neuralgic  pain,  extending  over  months  or  years  and  affect- 
ing one  or  more  branches  of  the  fifth  cranial  nerve,  with  no  discover- 
able cause.  The  mandibular  and  maxillary  divisions  are  affected 
in  most  cases;  the  supra-orbital  branch  rarely  is  affected  alone.  The 
attacks  may  be  brought  on  by  a  draft  of  air,  by  touching  the  side  of 
the  face  affected,  by  putting  food  into  the  mouth,  etc.  The  skin 
may  become  so  hyperesthetic  that  for  weeks  or  months  the  patient 
may  be  unable  to  wash  his  face;  he  may  be  unable  to  eat  because  of 
19 


290  INJURIES  AND  DISEASES  OF  NERVES 

pain  aroused  in  the  lingual  and  inferior  dental  nerves;  and  a  state 
bordering  on  insanity  may  ensue  finally  unless  relief  is  obtained. 

Treatment. — It  shoidd  be  ascertained  whether  any  local  or  con- 
stitutional cause  for  the  neuralgia  exists;  and  such  conditions  should 
receive  appropriate  treatment.  If  the  disease  belongs  to  the  major 
neuralgia  type  no  treatment  will  be  of  long  avail  unless  it  acts  directly 
on  the  nerves  or  ganglion  itself.  The  administration  of  salicylates, 
quinin,  opium,  or  other  drugs  may  be  useful  to  allay  the  pain  tem- 
porarily and  thus  improve  the  general  health  before  surgical  treat- 
ment is  undertaken.  This  treatment  implies  destruction  of  the 
nerves  or  the  ganglion,  or  both.  The  operations  are  divided  into 
extracranial  or  peripheral  operations  and  intracranial  operations. 

Peripheral  Operations. — Injection  of  the  nerve  trunhs  with  alcohol 
(Schlosser,  1907)  has  entirely  superseded  injections  with  osmic 
acid,  as  originally  advocated  by  Bennet  in  1897.  These  substances, 
especially  alcohol,  destroy  the  nerve  at  the  point  of  injection,  and 
though  regeneration  may  take  place  relief  is  secured  for  from  six  to 
eighteen  months,  rarely  for  longer  periods.  The  longest  period  of 
relief  secured  in  my  own  cases  was  just  short  of  one  year.  Patrick, 
of  Chicago,  has  had  large  experience  with  alcohol  injections,  which  he 
makes  into  the  second  and  third  branches  where  they  emerge  from  the 
base  of  the  skull,  and  into  the  first  branch  at  the  supra-orbital  foramen. 
He  does  not  attempt  to  make  deep  injections  into  the  first  branch 
because  of  danger  to  other  structures  in  the  orbit.  He  uses  this 
solution : 

Gni.  or  c.c. 

I^ — Cocain  muriate 1 

Alrohol      ...  135 

Aquae  de-stillata; q.  8  ad     1.5  5 

The  internal  maxillary  artery  with  its  branches,  including  the  middle 
meningeal,  is  directly  in  the  field  of  operation  and  renders  deep  injec- 
tions hazardous.  But  Patrick  has  had  no  bad  results  on  this  score 
in  150  cases.  The  needle  is  12  cm.  long,  1.75  mm.  thick,  is  not 
acutely  sharp,  and  is  provided  with  a  stylet.  To  inject  the  second 
branch,  the  needle  is  inserted  at  the  lower  border  of  the  zygoma 
just  in  front  of  the  coronoid  process  of  the  mandible  (0.5  cm.  behind 
a  perpendicular  let  fall  from  the  posterior  edge  of  the  orbital  pro- 
cess of  the  malar  bone);  while  the  third  division  is  reached  from  a 
point  at  the  lower  border  of  the  zygoma  2.5  cm.  in  front  of  its  anterior 
root,  A  tingling  sensation  in  the  distribution  of  the  nerve  indicates 
that  it  has  been  reached.  Usually  the  nerves  must  be  sought  for 
cautiously  b}'  inserting  the  point  of  the  needle  in  different  directions. 
The  foramen  rotundum  lies  about  5  cm.,  and  the  foramen  ovale 
about  4  cm.  from  the  surface.  About  2  c.c.  of  the  solution  are 
injected  into  each  nerve.  "If  the  operator  feels  satisfied  that  the 
needle  is  in  the  nerve  (he  never  knows  it),"  writes  Patrick,  "less  is 
enough."  No  anesthetic  is  necessary.  The  injection  may  be  repeated 
in  a  few  days  if  the  first  attempt  pro^-es  unsuccessful.    If  bleeding 


NEURALGIA   OF  THE  FIFTH  CRANIAL  NERVE  291 

occurs  tlirou^'li  tlic  needle  tlie  stylet  should  be  rej)l;iced  and  the 
needle  left  iit  ,sifu  until  clotting  occurs;  I  punctured  a  large  branch 
in  one  case,  but  no  bad  effect  was  noted. 

Anihion  of  ihe  Peripheral  Nerves  (Thiersch,  1889)  is  a  more 
formidable  procedure,  and  usually  secures  no  longer  freedom  from 
pain.  The  nerves  arc  very  slowly  avulsed  ])y  wra])])ing  them  around 
a  forceps,  after  adequate  exposure.  Not  more  than  one  complete 
revolution  of  the  forceps  in  every  half  minute  should  be  made.  The 
su})ra-orbital  nerve  is  exposed  at  the  upper  margin  of  the  orbit;  the 
superior  maxillary  at  the  infra -orbital  foramen,  whence  it  may  be 
followed  into  the  antrum  of  Highmore  and  along  the  floor  of  the 
orbit;  and  the  inferior  dental  branch  is  reached  by  trephining  the 
angle  of  the  mandible.  The  lingual  nerve  may  be  reached  at  the 
same  time  as  the  inferior  dental  by  removing  some  of  the  ascending 
ramus  of  the  mandible  (G.  G.  Davis,  1908).  These  nerves  may  be 
avulsed  both  peripherally  and  centrally,  from  this  location,  but  it  is 
well  to  avulse  also  the  anterior  portion  of  the  inferior  dental  through 
the  mental  foramen. 

The  second  and  third  branches  of  the  fifth  ner\'e  may  also  be 
approached  extracranially,  at  the  base  of  the  skull,  by  various  routes, 
involving  more  or  less  tedious  and  delicate  operations.  These  methods 
were  employed  chiefly  before  the  general  adoption  of  Thiersch's 
method,  when  it  was  thought  necessary  to  do  a  formal  excision  of 
as  much  of  the  nerves  as  possible;  they  are  now,  I  believe,  very 
properly  abandoned. 

Intracranial  Operations. — Extirpation  of  the  Gasserian  ganglion 
was  proposed  by  INIears,  of  Philadelphia,  in  1884,  and  first  performed 
by  E.  Rose  in  1890.  Rose  employed  the  pterygoid  route,  trephining 
the  base  of  the  skull.  Hartley,  of  New  York,  and  Krause,  of  Altoona, 
independently  in  1892  proposed  the  temporal  route,  and  most  surgeons 
now  employ  some  modification  of  the  Hartley-Krause  method.  Owing 
to  the  difficulty  of  removing  the  entire  ganglion,  from  the  presence 
of  adhesions  and  its  intimate  relation  with  the  cavernous  sinus,  sixth 
nerve,  etc.,  many  of  the  earlier  operations  were  only  partial  excisions, 
and  well  merited  the  description  "bloody,  difiicult,  and  dangerous," 
which  is  still  applied  to  them  by  Da  Costa.  To  simplify  the  operation, 
Abbe  (1903),  merely  divided  the  second  and  third  branches  before 
they  left  the  skull,  and  interposed  a  strip  of  rubber  tissue  to  prevent 
their  reunion.  Spiller  (1901)  by  a  happy  inspiration  suggested  to 
Frazier  that  section  of  the  sensory  root  of  the  ganglion  would  amount 
to  a  physiological  extirpation  of  it,  since  this  root,  which  is  devoid  of 
neurilemma,  could  not  on  that  account  regenerate.  This  operation, 
as  pointed  out  by  Frazier,  is  easier,  is  attended  by  less  hemorrhage, 
does  not  expose  the  cavernous  sinus  or  sixth  nerve  to  injury,  leaves 
the  motor  root  (and  consequently  the  muscles  of  mastication)  intact, 
and,  finally,  involves  a  diminished  risk  of  keratitis,  which  was  so 
prone  to  follow  removal  of  the  entire  ganglion. 


292  I XJ CRIES  AND  DISEASES  OF  NERVES 

Frazier-Spiller  Operation. — A  flap  of  soft  parts  is  turned  down, 
care  being  exercised  not  to  injure  the  upper  branches  of  the  facial 
nerve.  A  sufficient  amount  of  bone  is  then  removed  from  the  temporal 
fossa,  with  trephine  and  rongeur,  and  the  dura  is  raised  from  the 
base  of  the  skull.  Frazier  always  ligates  and  divides  the  middle 
meningeal  artery,  as  it  leaves  the  foramen  spinosum.  The  bura 
covering  the  mandibular  division  of  the  nerve  is  then  incised,  and  the 
ganglion  exposed.  If  the  motor  root  is  seen,  it  should  be  separated 
from  the  sensory;  this  latter  is  then  divided  or  avulsed.  The  brain 
is  then  allowed  to  fall  back  on  the  base  of  the  skull,  and  the  soft 
parts  are  closed  with  drainage.  The  mortality  following  the  operation 
in  the  hands  of  skilled  operators  is  less  than  4  per  cent.  The  chief 
dangers  are  shock,  hemorrhage,  and  infection. 

After-care. — For  weeks  or  months  after  operation  the  eye  of  the 
same  side  should  be  most  carefully  protected  by  a  shield  (an  automo- 
bile goggle  is  suggested  by  Frazier),  as  destruction  of  its  protecting 
nerve  supply  renders  the  cornea  exceedingly  prone  to  trauma  and 
infection,  and  many  patients  have  lost  their  sight  from  this  cause. 

Sciatic  Neuralgia  or  Sciatica. — This  is  not  regarded  as  so  frequent 
a  lesion  now  as  formerly,  since  it  has  been  shown  that  in  most  cases 
the  disease  really  is  a  neuritis,  or  is  merely  referred  pain  due  to  pelvic 
(Fig.  582)  or  hip  disorders.  If  no  cause  of  referred  pain  can  be  dis- 
covered, and  if  rest,  antirheumatic  drugs,  counter-irritation  (blistering, 
cauterization),  and  other  palliative  methods  are  ineffectual,  the  surgeon 
may  be  tempted  to  adopt  operative  measures,  on  the  theory  that  the 
affection  really  is  a  neuritis,  from  infection  or  trauma,  with  perineural 
adhesions. 

Xeuredasis  may  be  secured  without  incision  by  forcibly  flexing  the 
thigh  on  the  abdomen  with  the  knee  fully  extended  (the  patient  being 
anesthetized) ;  or  by  exposing  the  sciatic  nerve  below  the  gluteus 
maximus,  either  on  the  inner  or  outer  side  of  the  biceps  muscle,  and 
stretching  it  over  the  finger  both  centrally  and  peripherally;  the 
patient  lying  on  his  face  it  is  safe  usually  to  employ  traction  sufficient 
just  to  raise  the  limb  from  the  table.  Xcurolysis  is  a  safer  and  more 
certain  operation;  the  sheath  is  opened  and  the  nerve  fibres  separated 
from  it  and  from  each  other  for  a  distance  of  several  inches;  Pers 
(1908)  has  adopted  this  method  47  times,  and  among  42  uncompli- 
cated cases  there  were  only  three  recurrences.  In  many  cases  the 
adhesions  extend  up  into  the  sciatic  notch,  and  the  completion  of 
the  operation  may  be  difficult.  Best  exposure  is  secured  by  splitting 
the  fibres  of  the  gluteus  maximus  at  the  level  of  the  great  sacrosciatic 
foramen. 

Tic  Convulsif  or  Spasmodic  Tic  is  a  form  of  neuralgia,  usually  not 
painful,  characterized  by  constant  and  often  severe  twitching  in  the 
muscles  supplied  by  the  aft'ected  nerves.  In  the  neck,  which  is  its 
most  frequent  seat,  it  produces  spasmodic  torticollis;  it  also  occurs 
in  the  face,  the  shoulder,  and  very  rarely  in  other  parts  of  the 
body.    ^Myotomy,  neurectasis,  neurotomy,  and  neurectomy  have  been 


TUMORS  OF  NEIiVES  293 

employed,  but  tlie  disease  always  recurs  in  other  muscles,  no  matter 
how  wide  the  primary  nerve  excision  may  have  l)een.  Some  neurolo- 
gists go  so  far  as  to  maintain  that  even  were  the  cortical  centres 
governing  the  region  to  be  excised,  neighboring  centres  would  take 
on  diseased  action.  At  present  cure  of  the  disease  seems  hojx'less 
by  operation,  tiiough  the  temporary  imjjrovement  usually  secured  is 
not  to  be  despised. 

Tumors  of  Nerves. — Fibrous  out-growths  sometimes  occur  on  the 
ends  of  nerves  in  an  ami)utation  stump  ("amputation  neuromas"), 
apparently  due  to  attenii)ts  at  regeneration:  the  nerve  fibres  turn 
back  upon  themselves,  being  unable  to  make  headway  forward,  and 
form  painful  bulbous  masses,  which  usually  have  a  strong  tendency  to 
recur  if  excised,  or  even  after  formal  re-amputation.  Such  growths  are 
rare  except  where  the  amputation  was  a  l)ungling  ()j)eration.  jMultiple 
tumors  occasionally  are  formed  along  nerve  trunks  or  at  the  ter- 
minations of  nerve  fibrils  in  the  skin.  This  disease  is  variously  known 
as  multiple  neuro-fihromatosis  (when  confined  to  nerve  trunks); 
von  Recklinghausen's  disease  (1881)  or  inoUusciim  fihrusum  (when 
occurring  in  the  skin);  and  Uanhenneurom  or  ylexijorm  neuroma, 
which  occurs  in  the  form  of  a  circumscribed  thickening  of  the  skin, 
due  to  out-growth  of  nerve  fibrils — a  condition  most  often  found 
in  the  neck  or  scalp,  sometimes  pigmented,  and  usually  congenital. 
Da  Costa  (1910)  compares  the  condition  of  nerves  in  a  plexiform 
neuroma  to  that  of  the  arteries  in  a  cirsoid  aneurysm.  This  disease, 
in  its  various  forms,  usually  has  been  considered  a  form  of  difi'use 
fibromatosis,  blastomatoid  in  character;  but  in  the  second  edition 
of  his  Pathology  (1910)  Adami  returns  to  v.  Recklinghausen's  original 
theory,  and  to  that  of  Klebs  (1889),  which  lately  has  received  support 
from  other  observers,  that  these  growths  originate  in  the  nerve 
fibrils  themselves,  and  should  be  classed  as  Neurinomas.  Excision 
of  one  or  several  of  the  multiple  growths  may  be  required  for  pain  or 
deformity:  those  on  the  nerves  sometimes  may  be  shelled  out  with- 
out destroying  the  continuity  of  the  nerve  trunk.  The  "plexiform 
neuroma"  sometimes  recurs  after  removal;  sarcomatous  changes  may 
occur,  though  they  are  not  very  frequent. 


CHAPTER  XII.5 
P^RACTURES. 

The  study  of  fractures  is  one  of  the  most  important  subjects  which 
can  engage  a  surgeon's  attention;  they  are  injuries  which  occur 
constantly,  in  all  classes  of  life,  and  under  all  circumstances.  Even 
a  general  practitioner  cannot  avoid  having  a  number  of  cases  under 

his  care  every  year;  and  no  cases 
contribute  as  much  to  the  fame 
or  discredit  of  the  man  who  treats 
them.  And  while  it  is  well  recog- 
nized that  the  most  skilful  and 
assiduous  treatment  cannot  in 
all  cases  succeed  in  giving  the 
patient  a  useful  and  comely 
limb,  yet  it  is  sadly  true  that 
many  of  the  bad  results  con- 
stantly seen  are  due  to  sheer 
ignorance  and  neglect  on  the 
part  of  the  practitioner. 

Classification. — Fracture  of  a 
bone  may  be  complete  or  incom- 
ylete.  The  latter  form  {green- 
stick  fracture)  occurs  almost 
exclusively  in  young  children, 
the  bone  fibres  in  the  line  of 
extension  (convexity)  being  com- 
pletely ruptured,  while  those  in 
the  line  of  flexion  (concavity) 
maintain  their  continuitv  (Fig. 
2()7). 

Fractures     may    be    subcuta- 
neous   {simple)    or    open    {com- 
jjound),  the  latter  term  implying 
that  the   seat  of  fracture    com- 
municates with  the  external  air 
through    a   wound   of    the    soft 
parts. 
Comminuted  fractures  are  those  with  more  than  two  fragments,  the 
lines  of  fracture  intercommunicating  (Fig.  208).    They  are  to  be  dis- 
tinguished from  double  {triple,  quadruple,  etc.)  fractures  in  w^hich  two 
(or  more)  separate  and  distinct  breaks  are  present  in  the  same  bone. 


Fig.  267.- — Green-stick  fracture  of  radius 
and  ulna  with  extreme  deformity.  Penn- 
sylvania Ho.spital. 


CI.ASSIFICATION 


21)-) 


M ullij)!)'  fiuK  tiirr  ( Fi<;-.  2(»U)  is  a  term  wliicli  should  he  reserved  for 
eases  with  hreaks  in  more  than  one  hone,  the  hones  aU'eeted  not  heing 
parallel  (liUe  the  rihs,  those  of  the  forearm,  the  le^',  hand,  ete.). 

Complindcd  fractures  are  those 
attended  l)y  some  other  serious 
injury  of  ihc  sumc  part,  as  rupture 
of  the  main  hhxxhessels,  erushin^ 
of  nerves,  disloeation  of  neighbor- 
ing joint,  etc.  A  fracture  of  the 
lower  end  of  tlie  femur  may  be  com- 
plicated by  a  fracture  of  the  skull, 
or  by  a  stab  wound  of  the  hmg,  but 
such  a  fracture  is  not  a  "compli- 
cated fracture  of  the  femur"  un- 
less the  popliteal  artery  is  ruptured, 
the  knee-joint  dislocated,  or  some 
other  serious  injury  exists  in  the 
immediate  neigliborhood  of  the 
fracture. 


Fio.  268. — Comminuted  fracture  of 
tibia  and  fibula,  a  few  hours  after  in- 
jury.    Episcopal  Hospital. 


Fig.  269. — Multiple  fracture  of  upper 
extremity.     Episcopal  Hospital. 


Direction.— Fractures  are  further  classified  as  longitudinal,  trans- 
verse, oblique,  spiral,  etc.  These  terms  are  self-explanatory^  and  ^are 
illustrated  in  the  accompanying  skiagraphs  (Figs.  270,  271,  272). 
Transverse  fractures  are  more  frequent  in  cancellous  bone,  and  when 


296 


FRACTURES 


occurring  in  the  shafts  of  long  bones  usually  are  due  to  direct  violence; 
whereas  ol)lique  and  spiral  fractures,  seen  almost  exclusively  in  the 
shafts  of  the  long  bones,  generally  are  due  to  a  twisting  force  trans- 
mitted from  a  distance;  and  longitudinal  fractures,  freciuently  extend- 
ing into  a  joint,  usually  are  caused  by  a  splitting  action.  A  depressed 
fracture  is  one  seen  almost  exclusively  in  the  skull,  in  which  the 
fragments  are  displaced  b>'  the  vulnerating  force  below  the  level  of 

the  surrounding  bone.  An 
impacted  fracture  is  one  in 
which  one  fragment  is  driven 
into  the  other,  and  remains 
fixed  (Fig.  306).  Subperios- 
teal fracture  is  one  in  which 
the  })eriosteum  wholly  or  in 
great  part  remains  unrup- 
tured. 

Epiphyseal  Separations.  — 
The  epiphyses,  or  articular  ex- 
tremities of  the  long  bones, 
may  be  detached  from  the 
shafts  (diaphyses)  by  separa- 
tion along  the  epiphyseal  line 
until  the  age  when  ossifica- 
tion is  complete  in  the  car- 
tilage which  unites  epiphysis 
with  diaphysis.  The  injury 
is  most  common  at  the  lower 
ends  of  the  humerus,  radius, 
and  femur;  it  is  seen  also,  but 
more  rarely,  at  the  upper  ends 
of  the  humerus,  femur,  and 
tibia,  and  at  the  lower  end 
of  the  tibia.  The  injury, 
in  all  its  aspects,  so  closely 
resembles  a  fracture,  as  to 
be  considered  by  common 
consent  along  with  such  in- 
juries. 

Mechanism.  —  Bones  may 
be  broken  in  four  different 
w^ays:  (1)  by  torsion;  (2)  by 
flexion;  (3)  by  distraction,  and  (4)  by  compression.  For  a  bone  to  be 
broken  by  torsion,  it  is  necessary  for  one  of  its  ends  to  be  free,  while 
the  other  is  fixed;  the  injury  always  is  indirect,  and  the  line  of  frac- 
ture usually  oblique.  When  a  bone  is  broken  by  flexion,  the  force 
may  be  either  direct  or  indirect.  All  fractures  by  distraction  are  due 
to  indirect  violence,  and  practically  all  produced  by  compression  result 
from  direct  violence. 


Fig.  270. — Longitudinal  (splitting)  fracture  of 
tibia  and  fibula  (involving  knee-joint).  Age, 
forty  years.    Episcopal  Hospital. 


CA  USES 


2'.»7 


Causes  of  Fracture.  Predisposing  Causes. — Tlicsr  arise  citluT  from 
the  (oiulitioii  of  the  patient  or  that  of  the  l)oiie  afl'eeted.  JJoiies  of 
the  a(j('(l  are  more  Hable  to  fracture,  heeause  more  brittle,  than  those 
of  yoimg  i)er.sons;  but  as  tlie  hitter  lead  more  active  lives,  and  are 
more  exposed  to  exciting  causes,  the  number  of  fractures  actually 
occurriufj  in  the  aj^ed  is  less  than  in  the  young.  Likewise  the  male 
.sv.r,  from  its  greater  ex])osure,  is  more  lia})le  to  fracture  than  the 
female.      Certain    r//,s7Y/.sT.s-    of  hones   render   them    more   liable  to  be 


Fig.  271. — Transverse  serrated  fracture  of 
humerus.     Episcopal  Hospital. 


Fig.  272. — Oblique  and  spiral  frac- 
ture of  femur.  Age  three  years. 
Episcopal  Hospital. 


broken,  especially  osteopsathyrosis  and  malignant  growths.  The 
situation  of  a  bone  may  predispose  it  to  fracture,  the  clavicle  being 
more  often  broken  than  the  scapula,  the  lower  than  the  upper  jaw', 
etc.;  and  the  function  of  a  bone  has  a  predisposing  influence,  the  bones 
of  the  extremities  being  broken  more  often  than  those  of  the  trunk. 

Exciting  Causes. — Fractures  may  occur  at  the  point  of  impact, 
from  direct  violence  (gunshot,  cart  wheel,  falling  brick,  etc.);  or  may 
be  due  to  transmitted  force  {indirect  violence),  as  fracture  of  the 
elbow  from  falls  on  the  hand. 


298  FRACTURES 

Fracture  by  mvscular  action  usually  is  a  variety  of  fracture  from 
indirect  violence,  one  end  of  a  long  bone  being  twisted  violently 
by  the  muscles  attached  to  it,  and  being  wrenched  loose,  as  it  were, 
from  the  other  end,  which  opposes  its  inertia  to  the  sudden  muscular 
impulse;  this  is  the  explanation  of  fractures  of  the  humeral  shaft 
from  throwing  a  ball  (Ashhurst,  1905).  Muscular  action  may  tear  off 
an  apophysis  (coracoid  process,  greater  tuberosity  of  humerus,  anterior 
superior  iliac  spine,  etc.),  or  may  break  the  patella  or  olecranon  by 
sudden  flexion  over  their  neighboring  condyles,  as  an  over-bent  lever. 

S prain  fractiire  (Callender,  1870)  is  due  to  separation  of  a  ligament 
from  its  point  of  insertion,  with  detachment  of  a  small  shell  of  bone. 

Spontaneous  or  Pathological  Fractures  are  those  due  to  preexisting 
bone  disease,  where  trauma  is  minimal,  as  in  fragilitas  ossium, 
secondary  carcinoma  of  bone,  etc. 

Symptoms  of  Fractures. — In  addition  to  a  history  of  injury,  which 
exists  in  all  cases  except  some  pathological  fractures,  there  are  both 
symptoms  and  physical  signs  by  which  a  diagnosis  of  fracture  can  be 
made  clinically,  with  very  few  exceptions;  in  such  exceptional  cases 
the  use  of  the  or-ray  nearly  invariably  will  reveal  the  true  nature  of 
the  lesion. 

Pain  and  Tenderness. — These  are  present  in  practically  every  case 
and  are  by  no  means  proportionate  to  the  apparent  degree  of  injury, 
some  very  severe  compound  comminuted  fractures  causing  the  patient 
less  discomfort  than  a  single  subcutaneous  break.  When  no  other 
physical  signs  are  present,  the  surgeon  should  always  suspect  a  fracture 
when  there  exists  persistent  localized  tenderness  of  a  bone,  following 
injury;  such  a  fracture  may  be  subperiosteal  or  impacted,  and  the 
surgeon  should  treat  such  a  case  as  one  of  fracture  until  the  incorrect- 
ness of  his  diagnosis  has  been  proved. 

Swelling,  Ecchymosis,  etc.,  are  present  to  some  degree  in  nearly 
all  cases  of  fracture  (Fig.  273),  owing  to  coincident  injury  of  the  soft 
parts;  but  they  have  no  special  significance.  Abrasion  over  the  seat  of 
fracture  usually  shows  that  the  break  is  due  to  direct  violence. 

Deformity  or  Displacement. — This  is  one  of  the  most  constant  and 
valuable  signs  of  fracture.  It  may  be  due  either  (1)  to  the  fracturing 
force,  or  may  occur  subsequently  (2)  from  muscular  action;  both 
these  factors  may  be  operative;  or  finally  it  may  be  caused  simply 
(3)  by  the  weight  of  the  limb. 

1 .  Deformity  from  the  fracturing  force  is  seen  best  in  impacted  and 
in  depressed  fractures.  In  fractures  with  great  displacement  other 
factors  as  well  usually  are  at  work. 

2.  Deformity  from  muscidar  action  is  seen  especially  in  the  long 
bones  of  the  extremities,  and  occurs  most  markedly  when  the  fracture 
is  close  above  or  below  the  attachment  of  powerful  muscles — as 
above  or  below  the  insertion  of  the  deltoid,  below  the  insertion  of 
the  iliopsoas  tendon,  above  the  origin  of  the  gastrocnemius,  etc.  In 
fractures  of  the  patella  and  olecranon  it  is  almost  the  only  cause 
of  deformity.  It  is  responsible  both  for  the  shortening,  and  for  the 
angular  deformity,  as  well  as  for  many  cases  of  rotatory  displacement. 


SYMPTOMS 


299 


Deforniity  from  nuiscular  action  is  dopenflent  in  part  on  the  natural 
fcn<si<))t  of  the  muscles,  in  j)art  on  inrolinitari/  conlractiou,  (spasmodic) 
from  reflex  nervous  action,  and  in  i)art  on  voluntary  action.  h\  the 
patient. 

1).  DcJ'onnili/  from  the  force  of  (/rariti/  is  seen  in  the  outward  rotation 
of  the  leg  whicii  occurs  in  fractures  of  the  fenuir;  in  the  deformity 
known  as  'Moss  of  tiie  carrying  angle"  in  supracondylar  fractures 
of  the  humerus;  in  the  dropping  of  the  shoulder  in  fractures  of  the 
clavicle,  etc. 


Fig.  273. — Ecchymosis  twenty-four  hours  after  fracture  of  surgical  neck  of  humerus, 
extravasation  occurring  in  course  of  long  tendon  of  biceps.     Episcopal  Hospital. 

Direction  of  Disijlacement.— This  may  be  longitudinal,  lateral, 
angular,  or  rotatory. 

1.  Longitudinal  disylacement  almost  always  consists  in  shortening: 
lengthening  is  seen  only  in  fractures  of  the  olecranon  and  patella,  and 
in  some  of  the  calcaneum;  in  fracture  of  the  lower  end  of  the  fibula, 
lengthening  of  this  bone  may  occur  from  inward  rotation  of  the  foot 
(Malgaigne,  1841).  If  the  fracture  is  transverse,  there  can  be  no 
marked  shortening  unless  there  has  first  been  lateral  displacement, 
as  the  amount  of  shortening  which  occurs  in  an  impacted  fracture 
rarely  exceeds  one  or  two  centimeters;  oblique  fractures,  however, 
permit  of  great  shortening  without  much  lateral  displacement.  If  the 
ends  of  the  fragments  are  displaced  so  far  as  to  pass  by  one  another, 
overlapping  is  said  to  exist,  the  more  prominent  fragment  overruling 
the  less  prominent.  In  fractures  of  the  femur  the  shortening  from 
overlapping  may  be  from  five  to  ten  centimeters  (Fig.  274).  In  many 
fractures  it  is  requisite,  and  in  most  it  is  highly  desirable,  to  take  the 
actual  measurements  of  the  sound  and  injured  limb  between  known 


300 


FRACTURES 


fixed  points  to  determine  whether  or  not  there  is  shortening,  and  not 
to  rely  on  the  evidence  of  the  eyes  alone  to  determine  this  point. 

2.  Lateral  or  transverse  displacement  has  been  mentioned  already; 
it  occurs  mostly  in  transverse  fractures,  and  when  marked  allows 
overlapping. 


Fig.  274. 


-Fracture  of  fcnuir,  fragments  overlapping  two  inches.     Plated. 
Episcopal  Hospital. 


3.  Angular  deformity  usually  results  from  the  fracturing  force.  This 
is  well  seen  in  cases  of  green-stick  fracture  (Fig.  2()7);  hut  it  may 
be  originally  caused  by  muscular  action,  and  usually  is  maintained 
by  this  or  by  the  force  of  gravity. 

4.  Rotatory  displacement  consists  in  the  fragments  being  twisted  on 
their  own  axis  in  opposite  directions,  either  from  muscular  action  or 
the  force  of  gravity.  In  fractures  of  the  radius  above  the  insertion 
of  the  pronator  radii  teres  the  upper  fragment  is  supinated  by  the 
biceps,  while  the  lower  is  pronated  by  the  pronator  teres;  in  fractures 
of  the  neck  of  the  femur  the  lower  fragment  is  rotated  outward  by 
the  force  of  gravity  and  the  external  rotator  muscles,  which  are 
more  powerful  than  the  internal  rotators. 


uiAdNosjs  :;(ii 

DispUiri'iiiint  iiuuj  )i(d  he  due  to  fracture,  but  to  some  otlicr  lesion. 
DislociitioMs,  old  joint-diseases,  exostoses,  as  well  as  other  aU'ectioiis, 
may  cause  deformity  with  shortening,',  an^Milarity,  or  rotation;  so 
the  surgeon  must  not  place  reliance  upon  deformity  alone  in  the 
diagnosis  of  fracture. 

Mobility.  -Preternatural  mobility  in  a  hone,  following  recent  injury, 
implying  as  it  does  motion  at  some  point  other  than  tlu;  joints,  is 
almost  j)athogn()monic  of  fracture;  but  the  normal  flexibility  of  some 
bones  (ribs,  fibula,  rachitic  bones)  should  not  be  mistaken  for  abnormal 
mobility.  In  some  cases  mobility  is  so  great  that  it  is  evident  at  a 
glance,  the  limb  swinging  flail-like  at  the  site  of  fracture;  in  others, 
especially  where  only  one  of  two  or  more  parallel  bones  is  broken 
(ribs,  metacarpals,  etc.),  mobility  may  be  difficult  to  detect.  In 
subperiosteal  and  impacted  fractures  it  is  entirely  absent;  and  in 
other  forms  of  fracture  it  may  be  impossible  to  detect  it  owing  to  the 
depth  at  which  the  bone  lies,  existence  of  swelling,  etc.  In  fractures 
close  to  a  joint,  and  in  those  in  which  the  line  of  fracture  is  wholly 
or  in  part  intra-articular,  no  mobility  may  be  demonstrable.  While  in 
a  fracture  a  false  point  of  motion  exists,  in  a  dislocation  the  mobility 
of  the  affected  joint  is  diminished. 

Crepitus. — Crepitus  is  a  term  used  to  describe  the  grating  sensation 
appreciable  by  palpation  and  frequently  also  by  auscultation  (a 
stethoscope  may  be  used),  when  the  ends  of  the  fragments  are  moved 
against  each  other.  When  present  in  connection  with  mobility,  the 
diagnosis  may  be  considered  estal)lished.  Crepitus  should  not  be 
mistaken  for  the  creaking  of  tenosynovitis,  nor  for  the  similar  sound 
produced  by  motion  of  some  diseased  joints;  nor  yet  for  the  crackling 
of  subcutaneous  emphysema.  Crepitus  may  be  absent,  owing  to 
the  ends  of  the  fragments  not  being  in  contact  (overlapping,  separa- 
tion), or  to  muscular  or  fibrous  tissues  intervening;  in  green-stick, 
impacted,  and  subperiosteal  fractures,  there  is  no  crepitus. 

Loss  of  Function  is  another  valuable  sign  of  fracture,  though  it  is 
by  no  means  universally  present.  Patients  with  fracture  of  the 
fibula  may  continue  at  work,  and  apply  for  treatment  only  because 
of  deformity  or  persistent  disability;  the  same  is  true  of  fractures 
of  the  ribs;  and  of  some  fractures  in  which  pain  is  absent  owing  to 
nerve  lesions,  or  in  which  it  is  not  appreciated  owing  to  the  develop- 
ment of  mania  a  potu,  etc. 

Circumstantial  Evidence  of  fracture,  in  addition  to  the  above  men- 
tioned direct  signs,  is  afforded  by  various  occurrences:  subcutaneous 
emphysema  corroborates  a  diagnosis  of  fracture  of  the  nasal  bones, 
discharge  of  cerebrospinal  fluid  from  the  ear  indicates  a  fracture  of 
the  middle  fossa  of  the  skull,  etc. 

Diagnosis  of  Fracture. — If  a  surgeon  conscientiously  and  system- 
atically examines  the  patient  there  should  be  very  few  cases  in  which 
the  existence  or  non-existence  of  fracture  remains  doubtful.  Inquiry 
should  be  made  as  to  the  history  of  the  accident,  including  the  mode 
of  injury,  the  position  of  the  patient,  whether  the  lesion  is  due  to  a 


302  FRACTURES 

fall  of  the  patient,  or  to  his  being  struck  by  another  body.  If  he  fell, 
it  should  be  ascertained,  if  possible,  how  he  landed — whether  on  the 
outstretched  hand,  whether  his  foot  turned  in  or  out,  whether  his 
knee  suddenly  flexed  or  became  hyperextended,  whether  his  arm  was 
abducted  or  lay  across  the  thorax,  etc.  Occasionally  when  a  bone 
breaks  a  crack  is  heard. 

Inspection. — Inspection  may  show  the  patient  supporting  or  pro- 
tecting the  injured  part,  may  reveal  evident  deformity,  shortening, 
abrasion,  swelling,  etc. 

Palpation. — Running  the  fingers  lightly  along  the  surface  of  the 
suspected  bone,  the  point  of  greatest  tenderness,  nearly  always 
corresponding  to  the  site  of  fracttire,  can  soon  be  determined.  Sup- 
porting one  end  of  the  injured  bone  gently  but  firmly  in  each  hand, 
test  is  then  made  for  abnormal  mobility,  by  attempting  to  increase 
or  decrease  angular  deviation  of  the  fragment,  or  to  rotate  one 
fragment  on  the  other.  In  fractures  near  joints,  lateral  mobility, 
where  none  is  normally  present  (elbow,  knee)  may  thus  be  detected 
(in  dislocations  there  is  immobility  rather  than  aluiormal  mobility). 
In  most  cases  crepitus  will  be  elicited  during  the  manoeu\Tes  advised 
for  detection  of  mobility,  but  where  overlapping  exists  it  may  be 
necessary  first  to  bring  the  fractured  ends  into  apposition;  when 
crepitus  once  has  been  detected  it  is  reprehensible  to  make  attempts 
at  reproducing  it  merely  for  the  edification  of  bystanders. 

Mensuration.  —  ^Mensuration  has  been  mentioned  already  as  a 
valuable  means  of  detecting  shortening.  In  the  upper  extremity 
the  fixed  points  employed  are  the  tip  of  the  acromion  or  the  meta- 
cromial  tubercle,  the  condyles  of  the  humerus,  and  the  styloid  pro- 
cesses of  the  radius  and  ulna;  in  the  lower  extremity  measurements 
are  made  from  the  anterior  superior  iliac  spine  or  symphysis  pubis 
to  either  of  the  malleoli;  or  to  the  lower  border  of  the  patella,  head 
of  the  fibula,  etc.  By  placing  the  corresponding  limbs  in  similar 
attitudes  and  taking  repeated  and  accm-ate  measurements,  the  pres- 
ence of  shortening  usually  can  be  ascertained.  It  should  not  be 
forgotten,  however,  that  in  many  persons  the  two  lower  extremities 
normally  are  not  of  equal  length. 

It  is  important  to  make  a  correct  diagnosis  and  to  institute  proper 
treatment  as  soon  as  possible  after  the  injury  is  received;  deformity 
at  first  easily  appreciable  may  soon  be  obscured  by  swelling,  and 
not  only  will  the  diagnosis  then  be  more  difficult  than  if  made  at 
first,  but  reduction  of  the  deformity  and  other  proper  treatment 
will  be  less  eflectual  or  even  impossible  if  the  case  is  not  seen  early. 
In  all  cases,  moreover,  in  which  fracture  is  suspected,  the  case  should 
be  treated  as  if  fracture  were  present  until  the  contrary  is  proved. 

Skiagraphy. — Skiagraphy  is  a  great  aid  in  confirming  a  diagnosis 
of  fracture  tentatively  made,  or  in  disproving  its  existence  when 
one  is  suspected.  Whenever  possible  a  skiagraph  should  be  made 
before  the  patient  is  examined,  as  a  matter  of  record;  and  often  it  is 
desirable  for  the  surgeon  to  examine  the  plate  before  treatment  is 


PROCESS  OF   UNION  IN  FUAC'TUHED  BONES  iJOo 

instituted.  (\Tt;iiiiIy  after  reduction  has  heen  attenij)ted  it  is  well 
for  him  to  have  ocuhir  e\idenee  of  what  lie  has  accomplished;  and 
if  reduction  is  not  satisfactory  he  can  try  again.  In  making'  radio- 
graphs tlie  fihn  side  of  tlie  phite  is  phaced  next  the  patient's  liml), 
and  the  picture  etched  on  the  plate  is  the  shadow  of  those  parts 
iniper\ious  to  the  .r-rays.  In  looking  at  the  develojx'd  plate,  if  it 
is  held  with  the  film  side  toward  the  observer,  he  is  in  the  position 
occuj)ied  by  the  Crookes  tube  when  the  exposure  was  made,  and, 
therefore,  is  looking  at  the  shadows  of  tlie  bones  from  the  side  of 
cxj)osure.  In  taking  lateral  views  of  the  limbs,  that  bone  or  portion 
of  bone  nearest  the  plate  when  the  exposure  was  made,  will  be  most 
clearly  defined. 

Skiagraphs  ojicn  are  very  deceptive.  For  instance,  if  the  bones  overlap, 
and  lie  in  the  same  axis,  a  skiagraph  which  superposes  one  shadow 
on  the  other  may  show  no  fracture;  one  which  is  taken  in  the  same 
plane  as  that  in  which  angular  displacement  occurs,  may  show  no 
deformity.  Hence  it  is  a  good  rule  always  to  have  two  plates 
made,  exposure  being  in  planes  at  right  angles  to  each  other.  If  the 
Crookes  tube  is  too  close  to  the  limb  its  rays  will  be  quite  divergent 
when  impinging  on  the  skiagraphic  plate,  and  all  the  shadows  will 
be  exaggerated;  and  the  further  a  bone  lies  from  the  plate  the  more 
rays  it  will  intercept  and  the  larger  its  shadow  will  appear.  If  the 
Crookes  tube  is  not  accurately  centred  over  the  fracture,  the  shadows 
cast  by  the  fractured  ends  will  be  much  distorted,  perhaps  markedly 
exaggerating  the  deformity,  amount  of  callus,  etc.  In  passing  judg- 
ment upon  a  skiagraph,  therefore,  it  is  important  to  take  these  points 
into  consideration,  and  not  to  regard  as  evidence  of  malpractice 
phenomena  which  may  be  quite  easily  explained  in  other  ways. 

Prognosis  of  Fracture. — Prognosis  as  to  life  is  good.  In  large 
series  of  statistics  the  general  mortality  from  fractures  is  about  2.5  per 
cent.  Compound  and  complicated  fractures  have  a  higher  mortality. 
^Multiple  fractures,  as  I  pointed  out  in  1907,  in  studying  240  cases, 
give  a  mortality  of  about  25  per  cent.,  even  when  deaths  occurring 
soon  after  the  injury  from  hemorrhage,  shock,  visceral  injuries,  etc., 
are  excluded.  In  general  it  may  be  said  that  the  chief  causes  of 
death  in  fractures  of  any  variety  are  visceral  diseases  (pneumonia, 
uremia),  delirium  tremens,  and,  in  the  aged,  exhaustion. 

The  prognosis  as  to  the  function  of  the  fractured  part  depends 
more  upon  treatment  than  any  other  single  factor.  As  a  rule,  function 
is  more  quickly  and  completely  restored  in  children  and  young  adults 
than  in  the  aged;  and  in  those  of  sound  constitution  than  those  with 
rheumatic  or  gouty  tendencies. 

Process  of  Union  in  Fractured  Bones. — It  has  been  entirely  too 
much  the  custom  to  regard  bones  as  so  many  sticks  or  pieces  of  stone 
embedded  in  the  soft  tissues.  The  student  shoidd  disabuse  himself 
of  this  idea,  and  should  aim  constantly  to  remember  that  bone  is  a 
living  tissue,  composed  of  cells  and  intercellular  substance,  and  dilTer- 
ing  chiefly  in  the  composition  of  the  latter  from  other  tissues  such  as 


304 


FRACTURES 


muscle  or  epithelium.  Bone  reacts  to  injury  or  disease  in  very  much 
the  same  way  as  other  tissues;  the  phenomena  of  inflammation  and 
repair  may  appear  less  active  and  slower  than  in  the  soft  tissues, 
but  they  are  none  the  less  present.  A  glacier  is  a  fluid  body,  though 
it  looks  solid;  it  flows  slowly  and  invisibly,  but  none  the  less  surely; 
so  with  bone:  processes  measured  by  minutes  or  hours  in  soft  struc- 
tures may  take  days  or  weeks  in  bone,  but  they  are  the  same  in  kind. 
When  a  bone  is  broken,  the  surrounding  soft  parts  are  more  or  less 
damaged,  and  themselves  react  to  the  injury  by  the  process  of  inflam- 
mation as  described  in  Chapter  I. 
A  certain  amount  of  blood  is  extrav- 
asated  between  the  ends  of  the 
broken  bone,  and  the  various  cellular 
elements  of  the  tissues  in  the  injured . 
area  (bone  cells  from  the  marrow  and 
periosteum,  muscle  cells,  connective 
tissue  cells,  leukocytes,  etc.),  prolif- 
erate, and  aid  in  removing  debris  and 
causing  organization  in  the  mass  of 
inflammatory  lymph  which  is  formed. 
The  intercellular  substance  of  the 
bone  is  temporarily  absorbed  or  re- 
moved from  the  fractured  ends  by 
osteoclasts,  and  the  exudate  forming 
between  the  fragments,  which  is 
known  as  callus,  is  strictly  analogous 
to  the  inflammatory  lymph  which 
surrounds  it  and  with  which  it  is 
continuous.  The  ends  of  the  frag- 
ments thus  become  soft  and  sticky, 
and  may  be  compared  to  the  ends 
(if  a  broken  stick  of  sealing  wax 
which  one  seeks  to  weld  together 
JBM'  again  after  heating  in  a  flame.    This 

^^BHBm  callus    is    derived    largely   from   the 

^^^^^^HF  ^  medulla  of  bone,  by   proliferation  of 

^ I     osteoblasts.      This    portion    of   it    is 

known  as  interior  or  pin-callus,  while 
that  portion  formed  from  the  perios- 
teum is  known  as  ensheathing  or  ring- 
callus;    the   material    lying    between 
the  ends  of  the    compact    substance   of  the  bone  is  known   as  the 
yermanent  or  definitive  callus  as  distinguished  from  the  pin  and  ring 
callus,  which  is  called  provisional  or  temporary  callus. 

In  the  course  of  ten  days  or  two  weeks  the  callus  becomes  impreg- 
nated with  lime  salts,  that  derived  from  periosteum  often  passing 
through  a  cartilaginous  stage;  and  the  bone  can  no  longer  be  freely 
bent  at  the  seat  of  union  (Fig.  27o).     The  callus  gradually  becomes 


Fig.  27.5.  — •  Skiagraph  showing 
callus  several  weeks  after  fracture  of 
radius.    Episcopal  Hospital. 


PROCESS  OF  UNION  IN  FRACTURED  BONES  'M)5 

condensed  as  organization  proceeds  and  remains  only  as  a  sliglit 
thickening  at  the  site  of  previous  fracture;  but  the  pin  callus  usually 
is  not  entirely  absorbed,  and  complete  restoration  of  the  medullary 
canal  is  rare  If  there  has  been  exuberant  outpouring  of  callus  (Fig. 
27()).  it  may  cause  union  between  adjoining  bones,  may  interfere  with 
full  Hexion  or  extension  of  a  joint,  may  limit  rotation  in  the  forearm, 
may  grow  around  nerves  or  tendons,  or  cause  injurious  pressure  on 
them  or  on  vascular  channels,  resulting  in  trophic  changes,  edema,  etc. 


Fig.  276. — Skiagraph  of  exuberant  callus  from  fractures  of  elbow  and  forearm. 

If  the  fracture  is  subperiosteal  the  amount  of  ring-callus  formed 
will  be  inappreciable;  and  the  less  the  primary  displacement  and 
the  more  accurate  the  reduction  of  the  fractured  ends,  the  less  will 
be  the  amount  of  the  ring-callus.  In  fractures  of  the  skull  or  ribs, 
and  in  impacted  fractures,  where  displacement  is  slight,  no  appreci- 
able callus  is  formed.  If  the  periosteum  is  stripped  up  from  the  shaft 
of  a  bone  blood-clot  will  form  beneath  it,  as  well  as  between  the 
broken  ends,  and  becoming  organized  will  cause  thickening  of  the 
shaft,  as  the  periosteum  will  be  unable  to  fall  back  into  its  normal 
position  (Fig.  277).  The  periosteum  is  rarely  completely  detached 
from  the  broken  ends,  usually  remaining  at  least  on  one  side  as  a 
periosteal  bridge  (Oilier,  1867),  which  may  secure  firm  bony  union 
even  in  cases  where  marked  displacement  persists. 

The  process  described  above  usually  does  not  make  its  beginning 
manifest  for  several  days  after  the  occurrence  of  fracture,  and  is 
longer  delayed  in  comminuted  and  in  compound  than  in  simple 
20 


306  FRACTURES 

fractures.  In  multiple  fractures  it  is  a  very  usual  thing  for  one  or 
two  fractures  to  unite  in  the  ordinary  time,  and  for  the  other  fractures 
to  remain  ununited  until  those  first  uniting  are  quite  firm,  when 
union  may  commence  in  the  remaining  fractures.  In  simple  fractures 
fairly  firm  union  is  present  at  the  end  of  two  weeks,  though  at  this 
time,  and  in  larger  bones  for  some  weeks  afterward,  bending  at  the 
seat  of  fracture  still  may  occur.  An  adult's  femur  requires  usually 
eight  or  ten  weeks  for  absolutely  firm  union  to  occur.  It  is  said  that 
in  no  fracture  is  the  structure  of  the  bone  entirely  restored  until  a 
year  after  the  accident. 


Fig.  277. — Skiagraph  of  supracondylar  fracture  of  humerus,  showing  new-formed  bone 
beneath  bridge  of  periosteum,  three  weeks  after  injury.     Episcopal  Hospital. 

Delayed  union  is  a  relati^'e  term,  since  no  fixed  limits  can  be  set 
within  which  union  should  be  firm.  If  union  has  not  occurred  at  the 
end  of  ten  or  twelve  weeks,  it  is  usual  to  regard  the  case  as  one  of 
Non-union  or  Ununited  Fracture.  In  these  cases  the  tissue  between 
the  fragments  remains  in  a  fibrous  condition,  no  bone  salts  being 
deposited. 

Treatment  of  Fractures. — The  general  principles  already-  inculcated 
as  proper  in  the  treatment  of  inflammation  guide  the  surgeon  in  "the 
treatment  of  fractures.  The  indications  are  to  replace  the  broken 
bones  in  proper  position,  with  due  regard  for  the  condition  of  the  soft 


TREATMENT  OF  SlMl'LE  FRACTURES 


.)()/ 


parts,  to  ni((inf(tin  ihe  fraqntcid.s  in  proper  position,  and  to  drcKs  the 
injured  part  at  stiilahle  interrals  until  cure  is  complete. 

Treatment  of  Simple  Fractures. — Fractures  often  are  received  at 
a  distance  from  the  patient's  home  or  a  surge(m,  and  it  becomes 
necessary  to  transi)ort  the  ])atient  to  a  place  where  the  injury  can 
he  treated.  The  fractured  lind)  should  be  rendered  as  innnobile  as 
possible;  this  may  be  accomi)lislied  by  the  temporary  application 
of  any  aNailable  support  (shingles,  canes,  umbrella  ribs,  bark  of 
trees,  twigs,  etc.),  ai)plied  o\er  the  clothing  or  suita})Ie  padding,  or 
even  by  wra})i)ing  the  limb  firmly  in  clothing,  without  constriction; 
if  the  patient  is  unable  to  walk,  he  is  carried  on  a  shutter  or  on  a 
stretcher  improvised  from  poles  and  clothing,  to  his  home  or  the 
nearest  hospital. 


Fiu.  27s. — Showing  fragments  of 
brokon  bone  in  contact  "end-on,"  and 
with  not  too  much  lateral  displacement 
for  firm  union. 


Fig.  279. — Fragments  displaced  later- 
ally and  with  angular  deformity;  contact 
not  sufficient  for  firm  union. 


1.  Reducing  the  Fracture.  This,  which  often  is  expressed  by  the 
term  ".setting  the  bone,"  is  a  relative  term,  since  comparatively 
few  broken  bones  can  be  accurately  restored  to  their  original  form; 
and  in  the  case  of  shafts  of  long  bones  it  is  not  always  necessary 
that  reduction  should  be  accurate.  Nevertheless,  the  aim  must  be  to 
secure  as  accurate  reduction  as  possible,  and  in  the  case  of  fractures 
near  joints  (especially  the  elbow  and  ankle)  it  is  extremely  important 
to  do  so;  but  in  the  middle  of  the  shaft  of  a  long  bone  it  is  sufficient 
to  secure  firm  bony  union,  wath  no  appreciable  shortening,  with  preser- 
vation of  the  normal  axis  of  the  limb,  and  without  rotation  of  one  frag- 
ment on  the  other.  For  the  first  and  second  results  to  be  obtained 
it  is  necessary  for  the  fragments  to  be  in  contact  "end-on,"  not  only 


308  FRACTURES 

by  lateral  contact;  and  for  the  lateral  displacement  not  to  exceed 
two-thirds  of  the  diameter  of  the  bone  (Figs.  27S  and  279).  The  axis 
of  the  limb  sometimes  may  be  preserved  without  end-to-end  contact 
of  the  fragments,  but  it  is  very  rare  for  firm  union  to  be  secured 
(except  in  children),  and  shortening  never  will  be  absent  unless 
end-to-end   contact  is  obtained. 

The  methods  of  securing  reduction  are  many,  and  will  be  described 
when  the  injuries  of  the  individual  bones  are  discussed.  It  is  sufficient 
to  point  out  here  that  other  than  manual  force  seldom  is  necessary, 
if  the  surgeon  takes  advantage  of  the  relaxation  of  the  muscles  which 
may  be  secured  by  position  of  the  limb;  rarely  will  anesthesia  be 
necessary,  and  still  less  often  operative  intervention  (p.  130).  Secur- 
ing muscular  relaxation  by  position,  the  surgeon  with  his  hands 
makes  extension  and  counter-extension  on  the  broken  bone,  and, 
by  gently  but  firmly  a})plied  direct  pressure,  pushes  the  ends  of  the 
fragments  into  contact:  if  reduction  has  been  properly  secured, 
there  will  be  distinct  crepitus  as  the  broken  ends  come  together, 
the  normal  length  of  the  1  mb  will  be  restored,  and  bony  deformity 
will  disappear.  It  then  becomes  necessary  merely  to  maintain  reduc- 
tion until  union  is  sufficiently  firm. 

2.  Maintaining  the  Fragments  in  Apposition.  For  this  purpose  it 
is  usual  to  employ  splints  or  other  external  support,  held  in  place 
by  bandages,  plasters,  etc.  Splints  are  made  of  various  materials 
(wood,  tin,  wire,  gypsum,  etc.),  and  of  various  special  forms.  These 
will  be  described  when  discussing  fractures  of  the  several  bones. 
It  is  above  all  things  important  to  recognize  the  fact  that  splints 
are  not  used  for  the  purpose  of  overcoming  deformity,  but  merely 
to  maintain  the  limb  in  correct  position  after  the  deformity  has  been 
reduced.  The  action  of  splints  in  this  regard  may  be  much  assisted 
by  the  position  in  which  t'he  limb  is  dressed,  and  by  the  use  of  iveighi 
extension  to  overcome  spasmodic  muscular  contraction.  If  a  fracture 
is  close  to  a  joint  it  is  necessary  to  immobilize  the  joint  also;  in 
general  terms,  it  is  desirable  to  immobilize  so  much  of  the  limb  as 
will  prevent  any  lever  action  being  transmitted  to  the  site  of  fracture 
by  movement  of  the  portions  of  the  limb  left  free. 

Before  a  splint  is  applied  it  should  be  covered  snioothly  with  raw 
cotton,  oakum,  or  some  similar  material  in  sufficient  amount  to  pre- 
vent painful  pressure  on  the  limb,  special  care  being  taken  to  protect 
bony  prominences,  superficial  nerves,  bloodvessels,  etc.  It  often  is 
well  to  apply  between  the  splint  and  its  padding,  and  over  the  ends 
of  the  fragments,  pads  suitable  to  prevent  recurrence  of  deformity, 
provided  no  pressure  is  exercised  which  might  injure  the  soft  parts. 
An  excellent  rule  is  never  to  apply  a  bandage  beneath  the  splints  around 
the  fractured  region:  in  all  fractures  there  is  more  or  less  injury  of 
the  soft  parts,  and  the  reactive  swelling  which  occurs  in  these  has 
demonstrated  on  numerous  occasions  the  danger  to  which  the  patient 
is  subjected  by  neglect  to  observe  this  rule;  a  bandage  which  seems 
loose  enough  when  first  applied  may  in  a  very  few  hours  become  so 


TREATMENT  OF  SIMPLE  FRACTURES  309 

tij^lit  as  to  f'aus(>  serious  constriction,  pcrliaps  rcsnltinj^  in  <i;a!ifi;rcne 
of  the  extremity.  Under  all  circnnistances  it  is  well  to  lca\-e  exposed 
the  tips  of  the  fingers  or  toes,  and  to  direct  the  nurse  or  the  nienihers 
of  the  patient's  family  to  examine  their  condition  at  frequent  intervals; 
should  any  interference  with  the  circulation  l)ecome  evident  the  dress- 
ings must  be  removed  at  once  and  be  re-aj)])lied  more  circumsi)ectly. 

At  the  first  visit,  the  surgeon  should  proceed  to  examine  the  injured 
member  as  described  at  p.  301;  but  he  should  not  attempt  to  reduce 
the  fracture  until  he  has  all  his  dressings  prepared  for  application. 

3.  The  after-care  of  a  fractured  bone  involves  removal  of  the 
(Iressing  frequently  enough  to  make  sure  that  the  soft  parts  are  in 
good  condition,  and  that  reduction  is  maintained  by  the  dressing 
employed.  The  surgeon  never  should  neglect  to  see  the  patient  on 
the  day  after  the  dressing  is  first  applied,  and  to  ascertain  for  him- 
self that  the  limb  is  in  good  condition,  and  that  the  dressing  is  com- 
fortable; an  imcomfortahle  dressing  always  is  inefficient  even  if  not 
positively  harmfid;  but  if  the  dressing  is  comfortable  it  is  not  desirable 
to  re-dress  the  limb  more  than  two  or  three  times  weekly  at  first, 
and  less  often  as  union  progresses.  As  the  splints  and  bandages 
are  being  removed  for  re-dressing,  the  surgeon  should  support  the 
fractured  part  in  such  a  way  as  to  substitute  his  support  for  the 
splints,  preventing  dislocation  of  the  fragments,  and  rendering  dress- 
ing of  the  fracture  entirely  painless.  While  this  support  is  main- 
tained, the  patient's  skin  should  be  sponged  oflf  gently  with  dilute 
alcohol,  employing  such  gentle  friction  as  will  stimulate  the  circula- 
tion. I  do  not  approve  of  massage  or  mobilization  in  the  treatment 
of  fractures,  except  in  so  far  as  they  are  unavoidable  in  procuring 
proper  care  of  the  soft  parts;  and  while  I  acknowledge  the  truth  of 
the  dictum  (Lucas-Championniere,  1910)  that  "a  certain  amount  of 
motion  between  the  fragments  encourages  the  formation  of  callus," 
I  am  firmly  of  the  opinion  that  even  the  most  careful  immobilization 
by  splints  allows,  and  proper  care  of  the  soft  parts,  as  above  indicated, 
provides  that  "certain  amount"  of  motion  which  is  desirable,  and  that 
any  surgeon  who  attempts  more,  in  the  vain  idea  that  he  is  following 
modern  teaching,  will  succeed  either  in  stirring  up  such  an  amount 
of  callus  (especially  in  children)  as  to  cause  deformity  and  injurious 
pressure  on  the  soft  parts,  or  will  (in  most  adults)  leave  his  patient 
with  an  imunited  fracture.  When  the  ends  of  the  bones  become 
"stick}^,"  and  no  tendency  to  displacement  exists,  the  surgeon  may 
then  begin  at  each  dressing  to  make  very  limited  degrees  of  passive 
motion  in  the  neighboring  joints,  meanwdiile  maintaining  support 
at  the  seat  of  fracture.  Under  no  circumstances  should  the  passive 
motion  cause  pain.  When  union  is  firm  enough  for  all  external 
support  to  be  discontinued,  function  usually  will  be  more  comfort- 
ably and  quickly  recovered  by  active  movements  by  the  patient 
himself,  than  by  further  attempts  at  passive  motion;  and  if  a  fracture 
has  been  treated  properly  in  the  first  place,  massage  rarely  will  be 
necessary  to  accelerate  the  cure. 


mo  FRACTURES 

Operative  Treatment  of  Simple  Fractures. — Tliere  are  only  two 
indications  for  the  "open  method  "  of  treating  simple  fractures, 
so  strenuously  advocated  by  Lane  (1905)  and  other  surgeons:  (1) 
If  the  fracture  cannot  be  reduced  properly  without  operation.  (2)  If 
proper  reduction  cannot  be  maintained  without  direct  fixation  of 
the  fragments. 

1.  When  Proper  lieduciion  is  hnpussihle. — Impossibility  is  here 
a  relative  term,  since  what  is  impossible  for  one  surgeon  may  not 
be  so  for  another;  and  I  use  the  qualification  "proper"  reduction, 
because  I  do  not  wish  to  imply  that  operation  is  indicated  whenever 
accurate,  exact,  perfect  anatomical  replacement  is  impossible,  but 
only  when  such  degree  of  reduction  as  is  described  at  p.  307,  as 
requisite  for  proper  function,  cannot  be  secured  without  open  opera- 
tion. The  chief  causes  of  irreducibility  are  muscular  spasm  (usually 
this  can  be  overcome  by  general  anesthesia,  weight  extension,  or 
sometimes  by  tenotomy),  interposition  of  muscle,  fascia,  etc.,  between 
the  fragments  (sometimes  this  can  be  overcome  by  manipulation 
under  an  anesthetic),  buttonholing  of  one  fragment  in  the  deep 
fascia,  joint-capsule,  etc.  (this  usually  requires  incision),  complete 
rotation  of  a  detached  fragment  (apophysis,  condyle,  etc.),  and  /;//- 
paction  of  the  fragments  (if  desirable,  which  is  not  always  the  case, 
this  usually  may  be  overcome  by  manipulation  with  or  without 
an  anesthetic.) 

2.  When  SuhscquctU  Displacement  Cannot  he  Prevented. — This  also 
is  a  relative  condition,  depending  upon  the  skill  of  the  surgeon  in 
devising  and  applying  efficient  retentive  apparatus,  and  upon  the 
extent  to  which  displacement  occurs.  In  the  aged  or  feeble  it  may 
be  wiser  to  permit  recovery  with  considerable  deformity  than  to 
undertake  an  inexpedient  operation.  Uncontrollable  displacement 
generally  is  due  to  the  nature  of  the  fracture  itself  (marked  obliquity, 
much  comminution,  etc.),  to  muscidar  action,  or  to  the  refractory 
conduct  of  the  patient. 

Apart  from  fractures  of  the  patella,  which  are  conceded  to  require 
operation  (because  of  irreducibility)  unless  positive  contraindications 
exist,  the  two  forms  of  injury  in  which  operation  is  most  often  urged, 
are  fractures  of  both  bones  of  the  forearm,  and  those  of  the  femur; 
so  far  as  I  am  aware,  however,  it  has  yet  to  be  shown  that  operative 
methods  in  these  instances  can  be  safely  applied  by  the  average 
surgeon,  or  that  he  can  secure  by  uniform  resort  to  operation  as 
satisfactory  results  in  as  large  series  of  consecutive  cases  as  have 
been  obtained  by  conservative  treatment. 

If  operation  is  decided  upon,  it  is  best  done  either  on  the  day  of 
injury  or  not  until  about  the  end  of  the  first  week,  or  early  in  the 
second  week  after  the  injury,  since  at  this  time  the  primary  swelling, 
etc.,  will  have  subsided,  and  any  callus  that  may  have  formed  still 
will  be  soft  and  easily  removed;  moreover,  infection  is  less  likely 
to  follow  than  if  early  operation  is  attempted.  The  operation,  u'hich 
should  be  strictly  aseptic,  consists  in  exposing  the  fracture  through  the 


OPERATIVE   TUKATMKNT  OF  HlMl'LE  FRACTURES         :U  1 

pr«iH'r  muscular  inU'rsi)a(r,  excising  exuberant  callus,  reiuovuig 
interposed  soft  tissues,  and  in  securing  reduction  (which  is  not  always 
easy)  if  possible  without  resection  of  bone.  Then  if  very  slight 
tendency  to  dislocation  of  the  fragments  exists  it  is  not  necessary 
to  use  mechanical  means  to  hold  the  ends  in  apposition,  ])rovided 
the  surgeon  feels  capable  of  maintaining  reduction  by  his  external 
dressings.  If  there  is  still  a  tendenc>'  to  displacement,  the  fragments 
(in  the  case  of  small  bones)  should  be  sutured  with  heavy  cliromic 
catgut,  which  will  not  be  absorbed  until  union  is  so  firm  as  to  prevent 
sul)seqiient  displacement;  in  the  case  of  the  femur  and  in  oblique 
fracture  of  the  til)ia  it  is  safer  to  use  a  metal  plate,  since  maintenance 


Fig.  280.— Hamilton's  drill. 


Fig.  281. — Fragments  united  by  two  wire 
sutures,  inserted  in  different  planes. 


of  reduction  bv  external  dressings  alone  usually  is  difficult.  The 
form  of  plates  \ised  by  Lane  (1905)  probably  is  best:  these  are  of 
steel,  of  various  sizes,  and  are  applied  to  the  bone  without  displacmg 
the  periosteum.  About  three  screws  are  inserted  in  each  fragment ;  the 
holes  are  bored  by  a  suitable  drill  (Fig.  280)  or  dental  engine,  should 
extend  into  the  medulla  and  should  be  slightly  less  in  diameter  than 
the  screws;  the  screws  should  have  round  heads,  should  have  the 
tliread  carried  up  to  their  heads  and  should  be  just  long  enough  to 
enter  the  medullary  cavity.  The  use  of  plates  has  almost  super- 
seded wire  sutures  "in  large  bones  (femur,  tibia,  humerus,  lower  half 
of  radius),  but  in  smaller  bones  (clavicle,  ulna,  fibula)  wire  sutures 
are  efficient  and  may  be  more  easily  applied;  it  is  best  to  use  two 


312  FRACTURES 

sutures,  at  right  angles  to  each  other  (Fig.  2<S1).  Silver  wire  is  much 
used,  but  it  is  decidedly  inferior  to  aluminum  or  phosphor  bronze 
wire,  which  is  much  more  pliable  and  stronger.  If  all  oozing  has 
been  controlled  by  ligature  or  suture,  the  wound  may  be  closed  Avith- 
out  drainage,  but  in  case  of  doubt  it  is  better  to  leave  a  rubber  tube 
in  the  wound,  for  twenty-four  to  forty-eight  hours. 

After  such  an  operation  the  process  of  union  is  apt  to  be  delayed, 
and  in  a  fair  proportion  of  cases  operated  on  by  the  average  surgeon 
a  mild  degree  of  infection  occurs,  and  only  fibrous  union  results.  If 
the  operative  treatment  of  simple  fractures  were  confined,  as  it 
should  be,  to  skilful  surgeons  with  all  the  facilities  afforded  by  the 
best  modern  hospitals,  no  doubt  better  results  would  be  obtained. 

Treatment  of  Complicated  Fractures. — Rvpture  of  the  main  artery  or 
vein  of  a  limb  complicating  a  fracture  of  the  part  requires  the  same 
treatment  as  when  no  fracture  is  present  (p.  233) ;  if  gangrene  follows 
amputation  should  be  done  at  the  site  of  rupture;  but  if  the  axillary 
artery  is  ruptured  in  a  case  of  fracture  of  the  upper  part  of  the  humerus, 
it  usually  is  sufficient  to  amputate  tlirough  the  seat  of  fracture;  and 
if  the  popliteal  artery  is  ruptured,  to  amputate  at  the  knee-joint  if 
the  fracture  is  below  the  knee,  and  tlirough  the  seat  of  fracture  if 
this  is  in  the  femur.  Injuries  of  nerves  require  immediate  suture, 
if  it  is  evident  that  function  is  completely  destroyed;  otherwise  oper- 
ation should  be  delayed  until  after  consolidation  of  the  fracture, 
since  recovery  from  contusion  may  be  nearly  complete.  A  severe 
rcound  of  the  soft  parts  usually  takes  precedence  over  the  fracture, 
and  must  be  treated  suitably  irrespective  of  the  latter;  if  sufficient 
to  render  certain  the  occurrence  of  gangrene,  amputate  at  the  point 
of  injury  to  the  soft  parts.  Dislocation  of  the  neighboring  joint, 
most  often  encountered  at  the  shoulder,  usually  requires  incision 
and  direct  replacement  of  the  luxated  fragment;  though  sometimes 
it  is  possible  to  secure  reduction  by  manipulation  after  putting  up 
the  fracture  in  splints;  operation  is  best  postponed  until  seven  or 
eight  days  after  the  injury. 

Treatment  of  Compound  Fractures. — If  the  limb  is  so  severely 
injured  that  gangrene  is  sure  to  occur,  or  if  it  would  prove  useless 
even  if  it  could  be  saved,  it  is  best  to  amputate  at  once;  the  site  of 
section  of  the  bones  in  such  cases  is  determined  by  the  condition 
of  the  soft  parts  available  for  making  flaps. 

A  fracture  which  is  made  compound  merely  by  the  protrusion 
of  the  bones  tlirough  the  soft  parts  is  much  less  dangerous  than 
one  in  which  the  soft  parts  have  been  crushed  or  pulpefied  by  the 
same  force  which  produced  the  fracture;  because  in  the  latter  case 
there  is  much  greater  devitalization  of  tissue,  infection  is  carried 
deeply  into  the  soft  parts,  and  comminution  of  the  bones  is  the  rule. 

A  compound  fracture  in  itself  requiring  amputation,  and  compli- 
cated by  a  simple  fracture  higher  in  the  same  limb,  usually  will 
require  amputation  at  the  highest  point  of  injury. 

A  compound  fracture  involving  a  joint  sometimes  requires  ampu- 


TREATMENT  OF  COMI'OUND  FRACTURES  313 

tat  ion  falniost  always  at  the  knee),  hut  conservative  treatment 
with  strict  antiseptic  methods  often  will  secure  a  useful  limh  e\'en 
if  motion  is  limited. 

If  it  appears  in  any  way  likely  that  a  useful  Hmh  can  he  saved, 
especially  in  the  upper  extremity,  the  surgeon  must  undertake  repair 
of  the  soft  parts  and  reduction  of  the  fragments  with  antiseptic 
methods  as  detailed  at  p.  H)7.  Jn  almost  every  case  the  jjatient  should 
be  anesthetized,  and  the  priiJiary  dressing  made  to  assume  the  character 
of  a  formal  operation.  If  the  ends  of  the  bones  project  through 
the  soft  parts,  they  should  not  be  reduced  until  after  the  entire 
wounded  area  has  been  surgically  cleansed.  The  wound  in  the  soft 
parts  frequently  has  to  be  enlarged,  to  permit  of  reduction  and  repair 
of  the  deeper  tissues  (Fig.  282).  It  seldom  is  necessary  to  resect  the 
ends  of  the  bones,  reduction  usually  being  possible  by  relaxing  the 
nuiscles  by  the  position  of  the  limb,  and  bending  the  bones  at  an 
angle  until  their  ends  meet,  then  using  the  apposed  fragments  as  a 
fulcrum  on  which  to  straighten  the  limb  out  again. 


Fig.  282. — Compound  fracture  of  humerus,  bone  protruding.     Photographed 
just  before  operation.     (See  Fig.  283.)     Episcopal  Hospital. 

Where  the  bones  are  much  comminuted,  such  fragments  as  are 
entirely  detached  should  be  removed,  while  those  that  are  partly 
adherent  should  be  replaced,  in  the  hope  that  they  will  aid  in  pro- 
curing union.  Often  the  soft  parts  are  stripped  so  widely  from  the 
bones  that  it  is  impossible  to  prevent  recurrence  of  displacement 
even  when  reduction  is  easy.  Under  these  circumstances  the  bones 
may  be  fixed  by  some  form  of  internal  splint  as  described  in  connection 
with  ununited  fracture  (Fig.  283);  usually  it  is  better  not  to  plate 
a  recent  compound  fracture  (since  bony  union  seldom  follows  such  a 
course),  but  to  postpone  the  plating  until  the  soft  parts  have  healed  and 
asepsis  can  be  assured.  Particular  attention  should  be  paid  to  suture 
of  nerves,  muscles,  and  tendons.  The  wound,  unless  very  slight, 
should  be  drained  for  about  forty-eight  hours;  by  arranging  the 
dressings  as  described  at  p.  166,  the  drainage  tube  may  be  removed 
without  disturbing  the  fracture.  In  the  lower  extremity,  a  gypsum 
splint,  trapped  over  the  seat  of  injury,  makes  a  very  good  appliance 
for  the  treatment  of  compound  fractures;  but  in  the  upper  extremity 
ordinary  splints  used  in  cases  of  simple  fracture  are  quite  satisfactory-. 


314 


PiiACTUREH 


Frequently  irrigation  (p.  1()8)  must  be  employed  for  several  clays 
to  ensure  vitality  of  the  limb;  and  the  frequency  of  dressings  must 
be  determined  l)y  the  condition  of  the  soft  parts.     Union  is  much 


Fig   283— Silver  plate  on  compound  fracture  of  humerus.     (See  Figs.  282  and  284.) 

Episcopal  Hospital. 


more  delayed  than  in  simple  fractures;  and  though  fibrous  union 
often  is  the  best  that  can  be  secured,  it  may  furnish  the  patient  with 
a  useful  limb  (Fig.  284). 


TREATMENT  OF  HADLY   UNIT  El)  ERACTUliES 


.Slf) 


Treatment  of  Badly  United  Fractures. — It"  the  case   is  seen   before 
firm  union   has  occnrred,  the  jxjsition  usually  may  he  imi)roved  by 


Fig.  2S4. — Fibrous  union  following  pltited  compound  fracture  of  left  humerus. 
(See  Figs.  282  and  283.)      Episcoi)al  Hospital. 

ju(Hfious  application  of  pads  under  the  splints,  or  even  by  refractur- 
ing  the  bones  manually  and  dressing  them  in  the  improved  position. 
The  question  whether  impacted 
fractures  should  be  reduced  is 
discussed  under  the  lesions  of 
the  various  bones.  If  the  case 
is  seen  first  after  bony  union 
has  occurred,  it  is  not  always 
advisable  to  attempt  reduction 
of  the  deformity  if  function  is 
good,  since  non-union  may  result, 
or,  even  if  firm  union  is  secured, 
loss  of  function  may  accompany 
it.  SJwrtcning,  as  such,  unless 
due  to  angular  deformity,  scarcely 
ever  can  be  remedied;  indeed, 
to  secure  end-to-end  apposition 
of  the  fragments  it  often  is 
necessary  to  resect  their  ends, 
thus  increasing  shortening;  and 
attempts  to  lengthen  a  bone  by 
oblique  division  usually  are  nulli- 
fied by  contractions  in  the  sur- 
rounding soft  parts.  On  these 
accounts,  operative  measures 
are  directed  toward  overcoming 
lateral  displacement,  rotatory  and 
angular  deformity,  or  to  the  re- 
moval of  exuberant  callus. 

Careful      skiagraphic       studies  pm.  285.— vicious  union  following  frac- 

should  be  made  of  the  fractured       ture  of  forearm:  angular  deformity  and  loss 

,      ^      ,  of  rotation.     Suitable  for  operation.     Epis- 

region,  so  that  the  surgeon  may      copal  Hospital. 


316 


FRACTURES 


plan  his  method  of  operation  in  advance.  In  some  cases  simple 
refrachire,  by  the  hands  or  osteoclast  (p.  420),  will  be  sufficient;  in 
others  (Fig.  285)  it  is  necessary  to  cut  down  on  the  fragments  and  resect, 
treating  the  case  then  as  one  of  ununited  fracture  (p.  31 S);  while  in 
still  others,  linear  or  cuneiform  osieoioiny  will  give  the  best  results. 


Fig.  286. — Deformity  from  irreducible  separation  of  lower  radial  epiphysis. 
(See  Fig.  287.)      Episcopal  Hospital. 

In  deformity  from  a  separated  epiphysis  it  is  better  usually  to  divide 
the  diaphysis  close  to  the  epiphyseal  line,  and  not  to  inflict  further 
damage  on  the  immediate  site  of  injury,  for  fear  of  interfering  with 
subsequent  growth  (Figs.  286  and  287). 


Fig.  287. 


-Osteotomy  of  radius  to  correct  deformity  shown  in  Fij^ 
Episcopal  Hospital. 


286. 


Ununited  Fractures. — The  distinction  between  delai/cd  union  and 
vnunited  fracture,  as  was  pointed  out  at  p.  306,  is  difficult  to  draw; 
save  that  in  the  former  condition  union  frequently  occurs  under 
conservative  treatment,  while  in  ununited  fracture  it  rarely  does. 
The  most  marked  degree  of  non-union,  constituting  pseudartJirosis, 
is  that  in  which  a  bursa  forms  between  the  ends  of  the  fragments, 
there  being  almost  a  flail-like  joint  present  (Fig.  288).-  In  ordinary 
cases  there  is  rather  dense  fibrous  tissue  between  the  ends  of  the 
bones,  which  are  pointed  and  atrophic;  and  while  this  may  prevent 
lateral  displacement  of  the  fragments,  it  allows  angulation  at  the 
seat  of  fracture. 

Causes. — The  chief  causes  of  non-union  in  fractures  are:  (1)  Failure 
to  secure  end-to-end  apposition  of  fragments.  (2)  Comminution  of 
the  fragments,  especially  in  compound  fractures.  (3)  Imperfect 
immobilization  soon  after  the  accident.  (4)  Interposition  of  soft 
tissues.      (5)  Constitutional  condition  of  the  patient,  rendering  his 


UNUNITED  FRACTURES 


317 


processes  of  repair  ineft'ectiial.  These  factors,  several  of  which  may 
co-exist,  are  mentioned  in  what  I  l)eHeve  is  their  order  of  frequency, 
with  the  possible  excej)tion  of  the  j)atient's  constitutional  condition, 
which  in  many  cases  undoubtedly  is  the  chief  cause  of  non-union. 
But  it  should  be  noted  that  interposition  of  soft  tissues,  though 
comparatively  infreciuent,  always  results  in  non-union  when  present. 

Diagnosis. — The  diagnosis  rarely  presents  difhculties,  if  the  seat  of 
injury  is  carefully  and  repeatedly  examined;  it  is  a  truism  to  state 
that  the  firmer  the  union  the  more  difficult  it  is  to  detect  motion. 
A  skiagraj)li  may  aid,  since  it  will  show  absence  of  bony  structure 
between  the  fragments. 

Treatment. — The  treatment  depends  upon  whether  the  patient  is 
seen  during  the  stage  of  delayed  union,  or  whether  he  first  comes 

imder  the  surgeon's  observation  when  non- 
union has  existed  for  months  or  years.  The 
surgeon  should  endeavor  to  ascertain  the 
cause  of  the  condition,  and  should  attend 
to  the  patient's  general  health,  administering 
cod  liver  oil,  phosphates,  thyroid  extract, 
etc.  If  separation  of  fragments  can  be 
excluded,  conservative  measures  should  be 
tried  first  In  the  case  of  delayed  union, 
the  first  thing  to  do  is  to  try  what  strict 
immobilization  for  a  period  of  four  to  six 
weeks  will  accomplish:  this  frequently  secures 
firm  union;  but  if  it  fails,  trial  should  be 
made  of  functional  use  of  the  part,  with 
the    fracture  supported   in    splints,  braces. 


Fig.  28S.  —  Pscudar- 
throsis  of  humerus  with 
ankylosis  of  elbow,  follow- 
ing compound  comminu- 
ted fracture.  Not  suita- 
ble for  operation.  Epis- 
copal Hospital. 


Fig.  2S9. — Moulded  binder's-board  splint,  for  delayed 
union  after  fracture  of  both  bones  of  forearm.  Epis- 
copal Hospital. 


etc. ;  and  of  rather  vigorous  massage  of  the  affected  limb.  A  fracture 
of  the  leg  bones  with  delayed  union  frequently  will  grow  firm  when 
the  patient  begins  to  walk  around  in  his  gypsum  ca.se;  for  delayed 
union  of  the  femur  a  well  fitting  walking  brace  is  more  efficient; 
while  for  the  humerus  or  forearm  a  light  splint  of  binder's-board 
to  support  the  seat  of  fracture  will  allow  free  use  of  the  hand  and 


318 


FRACTURES 


elbow.  The  patient  (Fig.  289),  a  skiagraph  of  whose  forearm  is  shown 
in  Fig.  347,  eured  his  own  delayed  union  by  returning  to  his  black- 
smithing  work,  securing  perfect  functional  use  in  spite  of  the  bony 
deformity,  which,  howe^'er,  was  not  appreciable  through  the  thick 
mass  of  muscles. 

Should  this  degree  of  stimulation  fail  to  develop  osseous  union, 
the  patient  may  be  anesthetized,  and  the  ends  of  the  bones  vigorously 
rubbed  together,  and  then  immobilized  for  a  few  weeks;  this  pro- 
cedure often  arouses  osteogenetic  processes  and  secures  firm  union 
when  milder  methods  are  ineffectual.  Bier  (1905)  advocates  stimula- 
tion of  osteogenesis  by  injecting  around  the  ends  of  the  fragments 
30  to  40  c.c.  of  venous  blood  freshly  drawn  from  the  patient. 

If  conservative  measures  fail,  the  question  of  operation  rises; 
but  in  every  case  the  surgeon  should  stop  to  consider  whether  any 
operation  is  apt  to  improve  matters,  or  whether  the  patient  has  not 

a  sufficiently  useful  limb  as  it  is.  The 
mere  doing  of  an  operation  does  not 
ensure  the  occurrence  of  bony  union;  it 
may  leave  the  patient  with  non-union, 
and  with  increased  shortening,  since 
resection  of  the  fragments  usually  is 
necessary.  But  where  deformity  can 
be  decreased,  and  disability  lessened, 
operation  is  indicated. 

Operation. — The  fracture  is  exposed 
through  the  proper  muscular  interspaccj 
exuberant  callus  is  removed  with  gouge, 
chisel,  and  Volkmann's  sharp  spoon,  and 
the  ends  of  the  fragments  are  freshened 
with  the  saw,  the  least  possible  amount 
of  bone  being  removed  which  exposes 
healthy  osseous  structure  and  allows 
proper  apposition.  In  some  cases  simple 
end-to-end  approximation  is  sufficient; 
in  others  a  form  of  mortise  and  tenon 
joint  is  preferable  (Fig.  290).  In  either 
case  it  is  desirable  to  fix  the  fragments, 
and  undoubtedly  the  best  way  to  secure 
this  and  to  encourage  osteogenesis  is  by  use  of  a  bone  transplant, 
taken  from  the  crest  of  the  patient's  tibia  (p.  504).  The  trans- 
plant may  be  set  in  the  medullary  cavity  (intramedullary  splint), 
or,  which  is  easier,  a  slot  may  be  cut  in  each  fragment,  and  the  trans- 
plant implanted  laterally  as  a  bridge.  In  the  hip  (ununited  fracture 
of  the  cervix)  I  have  secured  a  well-nigh  perfect  result  by  driving  a 
bone  peg  through  the  fragments  (Fig.  291).  The  use  of  such  trans- 
plants is  fast  superseding  the  employment  of  steel  plates  and  wire  in 
operations  for  ununited  fracture.  The  strictest  aseptic  technique  is 
requisite  to  secure  satisfactory  results. 


Fig.  290. — A  form  of  mortise 
and  tenon  joint  useful  in  opera- 
tions for  ununited  fracture. 


SI'ECIA  L  FR  ACT  IRES 


319 


The  wound  slioiild  not  \)v  (iraiiicd,  if  strict  licinostasis  has  been 
secured  before  ch)sing  it,  i)Ut  in  doubtful  cases  it  is  safer  to 
leave  a  tube  in  place  for  thirty-six  to  forty-eif,dit  liours.  If  a  sinus 
persists  after  recovery,  as  sometimes  is  the  case  when  the  plate 
or  wire  suture  has  been  used,  the  foreign  body  should  l)e  removed, 
otluTwise  it  may  be  allowed  to  remain  indefinitely.  Dr.  Edward 
Martin  has  recently  removed  a  silver  plate  inserted  by  my  father, 
which  only  at  the  expiration  of  seventeen  years  began  to  work  loose 
and  produced  a  simis. 


Fig.  291. — Ununited  fracturo  of  the  neck  of  the  femur  treated  V^v  l)one  transplan- 
tation.    Bony  union;  no  shortening;  free  motion,     f^jii.scopal  Hospital. 


SPECIAL  FRACTURES. 

The  general  subject  of  fractures  and  their  treatment  has  been 
so  fully  discussed  in  the  preceding  pages,  and  so  many  excellent 
monographs  on  the  subject  are  readily  obtainable,  that  in  speaking 
of  the  injuries  of  the  several  bones  I  shall  be  as  brief  as  possible. 
As  fractures  of  the  skull  and  of  the  spine  are  of  interest  chiefly  in 
connection  with  injuries  to  their  contained  structures,  their  con- 
sideration is  postponed  to  Chapter  XVI  and  XVII  respectively. 


320 


FRACTURES 


FRACTURES  OF  THE  FACE  BONES. 

Injuries  of  the  face  bones  are  due  almost  without  exception  to 
direct  violence;  edema  and  ecchymosis  often  are  marked,  owing 
to  the  abinidance  of  loose  cellular  tissue  overlying  the  bones,  and 
hemorrhage  into  the  nasal  or  oral  cavities  is  quite  frequent,  the 
fractures  being  compound  on  the  mucous  surface.  Antiseptic  sprays, 
mouth  washes,  etc.,  are  indicated  under  such  circumstances.  Union 
occurs  rapidly. 


Fiu.  292, — Fracture  of  nose,  ciiihtecn  hours 
after  injury.     Episcopal  Hospital. 


Fig.  293. — Fracture  of  risht  malar 
bone,  from  pressure  by  elbow  in  playing 
basket  ball.     Episcopal  Hospital. 


Nasal  Bones. — These  may  be  crushed  directly  inward,  or  as  is 
more  often  the  case,  may  suffer  lateral  deviation.  The  epistaxis  fol- 
lowing the  injury  usually  subsides  in  a  few  minutes.  The  deformity  is 
characteristic,  and  the  diagnosis  usually  is  made  by  inspection  (Fig. 
292),  and  is  confirmed  by  crepitus  as  the  displacement  is  corrected. 
This  often  may  be  accomplished  by  external  pressure,  but  in  some 
cases  is  more  effectually  secured  by  leverage  from  within  by  a  bone 
elevator.  There  is  no  marked  tendency  for  recurrence  of  deformity, 
and  retentive  appliances  generally  are  useless  save  to  protect  the 
part  from  injury.  A  strip  of  adhesive  plaster  may  be  carried 
across  both  cheeks  and  the  bridge  of  the  nose,  as  a  precaution.  As 
swelling  subsides,  deformity  may  appear  more  evident,  and  often  it 
is  desirable  to  mould  the  nose  into  shape  by  pressure  every  day  or  so 
during  the  first  week.  Rarely  can  complete  symmetry  be  restored. 
Union  is  firm  in  ten  days  or  two  weeks. 

Malar  Bone. — This  is  rarely  fractured.  Usually  there  is  depression, 
(Fig.  293)  which  is  best  overcome  by  early  incision  under  an  anesthetic 
and  direct  elevation  of  the  fragment.  Fractures  of  the  zygoma  often 
are  comminuted,  and  require  the  same  treatment. 


FRACTURES  OF  THE  FACE  BONES 


321 


Maxilla.  Fractures  of  this  bone  are  not  frequent,  but  sometimes 
occur  with  luuhipk"  fractures  of  tlie  face.  They  are  often  compound 
into  tlie  nose  or  moutli.  Asynunetry  of  the  alveolar  process  is  the 
main  diaf;;nostic  point.  Impaction  is  usual,  and  must  be  reduced 
to  restore  symmetry.  If  maintenance  of  reduction  proves  difficult,  it 
is  well  to  liave  a  special  splint  constructed  l)y  a  competent  dentist 
(Aller,   1914). 

Mandible.— Fracture  of  the  lower  jaw  is  the  most  important,  and, 
with  excei)tion  of  the  nasal  bones,  probably  the  most  frequent  of 
those  of  the  face.  It  is  due  frequently  to  a  blow  from  the  fist,  some- 
times to  the  kick  of  a  horse,  to  sudden  jerkinj?  upward  of  a  mule's 
head,  or  to  a  fall.  Fracture  involves  either  the  body  of  the  bone, 
the  condyle,  or  the  coronoid  j^rocess. 


Fig.  29-4. — Skiagraph  of  fracture  of  mandible  in  front  of  angle.     Age  twenty- 
seven  j-ears.     Episcopal  Hospital. 


Fracture  of  the  body  of  the  mandible  occurs  either  near  the  symphysis, 
or,  most  often,  anterior  to  the  insertion  of  the  masseter  muscle.  A 
rare  fracture  is  detachment  of  the  mental  eminence,  carryiiig  the 
genial  tubercles,  and  (by  relaxation  of  the  geniohyoid  and  geniohyo- 
glossus  muscles)  permitting  the  tongue  to  fall  backward,  perhaps 
suffocating  the  patient;  this  fracture  requires  immediate  operation 
with  suture  of  the  fragment  (G.  G.  Davis,  1894).  A  similar  condition 
may  exist  in  a  double  fracture  of  the  jaw,  on  each  side  of  the  symphysis. 
Fracture  in  front  of  the  masseter  muscle,  or  posterior  to  the  mental 
21 


322  FRACTURES 

foramen,  is  the  most  fre()ueiit  injury:  tlie  line  of  fracture  usually 
is  bevelled,  permitting  separation  of  the  fragments  as  the  posterior 
is  drawn  toward  the  middle  line  by  the  mylo-hyoid  and  internal 
pterygoid  muscles;  the  corresponding  muscles  of  the  uninjured  side 
increase  the  deformity  by  acting  similarly  on  the  unbroken  side  of 
the  jaw  (Fig.  294).  In  most  cases  good  results  follow  immobilization 
for  three  or  four  weeks  by  a  modified  Barton  bandage  using  the 
upper  jaw  as  a  splint;  tendency  to  displacement  becomes  less  a  few 
days  after  the  injury.  Fixation  by  a  special  interdental  splint  of 
gutta-percha,  such  as  is  made  by  dentists,  though  it  may  be  un- 
necessary, undoubtedly  promotes  the  patient's  comfort,  and  recovery 
ensues  with  little  or  no  deformity.  Double  or  compound  fractures 
frequently  require  operation,  with  wiring  of  the  fragments. 

Fracture  through  the  neck  of  the  condyle  is  a  serious  injury,  often 
leading  to  ankylosis  (p.  659):  the  external  ptyergoid  muscle,  attached 
to  the  condyle,  rotates  its  broken  surface  forward,  and  as  it  is  very 
difficult  to  replace  this  by  manipulation,  operation  is  indicated.  If 
the  fracture  is  overlooked  in  children,  disuse  of  the  jaw  following 
ankylosis  may  result  in  marked  retrognathism. 

Fracture  of  the  coronoid  process,  a  very  rare  accident,  is  difficult 
to  detect,  as  separation  of  the  fragment  is  prevented  by  attachment 
of  the  temporal  muscle  far  down  the  inner  side  of  the  ramus.  Treat- 
ment consists  in  procuring  rest  by  bandages  until  acute  symptoms 
subside. 

FRACTURES  OF  THE  BONES  OF  THE  TRUNK. 

Sternum. — This  is  an  unusual  fracture,  generally  due  to  direct 
violence,  the  patient  being  crushed  beneath  a  fall  of  earth,  etc.; 
some  cases  are  due  to  muscular  action,  such  as  violent  lifting  effort, 
parturition,  etc.  Visceral  injury  is  to  be  feared,  especially  in  cases 
caused  by  direct  violence;  it  is  manifested  by  hemoptysis,  dyspnea, 
cyanosis,  subcutaneous  emphysema,  etc.  The  line  of  fracture  usually 
is  transverse,  and  sometimes  consists  in  a  diastasis  between  the 
manubrium  and  gladiolus;  more  often  a  true  fracture  exists  above 
or  below  this  joint,  the  lower  fragment  projecting  in  front  of  the 
upper.  Attempts,  not  always  successful,  are  made  to  reduce  the 
deformity  by  hyperextension  of  the  spine  over  a  small  pillow,  and 
drawing  the  arms  backward.  Crepitus  may  be  detected  during  this 
manoeuvre.  The  sternal  region  is  then  immobilized  by  l)road  strips 
of  adhesive  plaster,  passed  from  axilla  to  axilla,  while  the  chest  is 
collapsed  in  expiration.  In  uncomplicated  cases  recovery  is  rapid, 
union  being  firm  in  three  or  four  weeks.  Suppuration  may  follow 
in  case  of  extravasation  into  the  anterior  mediastinum,  and  is  to 
be  treated  by  intercostal  incision  or  trephining  the  sternum. 

Fracture  of  the  ensiform  process  may  unite  with  deformity;,  the 
xiphoid  being  turned  backward  and  causing  gastric  distress  {xipho- 
dynia).    This  is  best  relieved  by  excision  of  the  xiphoid. 


Fh'AtTLh'ES  OF   Tin<:   HOSES  OF   THE    THINK 


Ribs.  Fractures  of  the  ribs  dispute  with  those  of  tlie  clavicle 
the  first  place  in  freciuency  amoug  all  fractures.  The  injury, 
couuuonest  in  male  adults,  may  be  caused  by  direct  or  indirect 
violence;  in  the  latter  case  the  force  usually  is  applied  antero-pos- 
teriorly,  and  the  ribs  break  at  their  weakest  point  when  the  limit 
of  elasticity  has  l)een  reached.  The  ribs  most  often  broken  (usually 
two  or  more  at  once)  are  those  from  the  fifth  to  the  ninth,  usually 
in  the  axillary  or  posterior  axillary  line.  There  is  great  pain  on 
forced  ins})iration,  and  on  sudden  motion;  localized  tenderness, 
sometimes  distinct  mobility  and  crepitus.  By  using  a  stethoscope 
crepitus  can  be  detected  in  almost  all  cases,  and  may  be  traced  up 
to  its  origin  even  from  a  distance.  \  isceral  complications  are  unusual 
but  serious;  they  should  be  looked  for:  subcutaneous  emphysema 
indicates  j)artial  rupture  of  the  lung;  hemothorax  is  a  grave  compli- 
cation, and  traumatic  pneumonia  very  fatal. 

Treatment. — Treatment  comprises  immobilization,  but  rarely  con- 
finement to  bed.  Broad  strips  of  adhesive  plaster  are  applied,  at 
the  end  of  each  forced  expiration  and 
with  the  arm  on  the  affected  side  depen- 
dent; they  run  from  below  upward,  begin- 
ning at  the  spine,  and  extending  Just  to 
beyond  the  midline  in  front  (Fig.  295). 
Immobilization  of  both  sides  of  the  chest 
is  undesirable.  This  strapping  should  be 
renewed  as  often  as  it  comes  loose,  every 
five  or  six  days;  and  should  be  continued 
for  four  or  five  weeks.  For  the  persis- 
tent pain  and  neuralgia  which  sometimes 
follow  these  injuries,  massage  and  anti- 
rheumatic remedies  may  be  tried;  the 
disability  seldom  persists  long.  The  treat- 
ment of  injuries  of  the  thoracic  viscera  is 
considered  in  Chapter  XX  (p.  73.3). 

Costal  Cartilages.  —  These  sometimes 
become  detached  at  their  junction  with 
the  ribs.  Treatment  is  similar  to  that 
for  fracture  of  the  ribs. 

Pelvic  Bones. — These  fractures  usually 
are  caused  by  direct  violence,  and  are  of 
interest  chiefly  from  their  visceral  compli- 
cations, which  are  met  with  in  about  one- 
sixth  of  the  cases  (Ashhurst,  1909),  the 
general  mortality  being  over  30  per  cent. 

The  most  important  are  those  fractures  which  break  the  ring  of  the  pelvis: 
when  the  force  is  received  antero-posteriorly,  as  when  a  heavy  weight 
knocks  a  man  down  and  lands  on  his  symphysis  pubis,  the  anterior  part 
of  the  peh'is  is  crushed  inward,  fracturing  the  rami  of  the  pubes  and 
ischium  on  one  or  both  sides  or  bursting  the  symphysis  pubis,  and 


Fig.  295. — Adhesive  plaster- 
strapping  for  fracture  of  ribs, 
applied  with  arm  dependent;  arm 
raised  before  photograph  was 
taken.     Episcopal  Hospital. 


324  FRACTURES 

spreading  the  halves  of  the  pelvis  apart,  perhaps  causing  diastasis  of  the 
sacro-iliac  joints,  or  fracture  of  the  ilium  through  the  sacro-sciatic  notch 
(Fig.  296) .  When  the  force  is  received  laterally,  the  most  frequent  frac- 
ture which  involves  the  ring  of  the  pelvis  is  a  vertical  fracture  in  the 
neighborhood  of  the  symphysis  pubis,  and  one  of  the  ilium  behind 
the  acetabulum;  but  force  transmitted  through  the  femur  may  cause 
comminuted  fracture  of  the  acetabular  region,  not  invohing  the  yelvic 
ring.      Of    fractures    which    do   not   involve   the   pelvic  ring  those 


Fig.  296. — Fracture  of  pelvis,  from  antero-posterior  force.  Note  diastasis  of  sym- 
physis; fracture  through  innominate  bone  from  iliac  crest  to  sacrosciatic  notch; 
separation  of  sacro-iliac  joint.    Recovery.    Episcopal  Hospital. 

detaching  one  of  the  iliac  crests  are  most  frequent,  usually  being  due 
to  lateral  force  (Fig.  237),  though  the  anterior  superior  spine  alone  has 
been  detached  by  muscular  action.  The  various  fractures  are  not 
difficult  to  diagnose,  as  displacement  usually  is  quite  appreciable  to 
palpation,  which  should  always  include  rectal  or  vaginal  examination. 
If  displacement  is  slight,  persistent  localized  tenderness,  especially  of 
one  of  the  pubic  rami,  is  a  valuable  sign;  and  a  skiagraph  may  aid. 
Crepitus  often  is  evident  on  attempts  at  motion;  pain  is  experienced 


FRACTURES  OF  THE  BONES  OF  THE   TRUNK  325 

wlicn  the  troclianteric  regions  are  erowded  together,  or  when  attempts 
are  made  to  move  one  innominate  bone  on  tlie  otlier.  While  ojjrnitwii 
may  he  re(|nir('d  for  visceral  eom])licatio!is  (ru))tnre  of  urethra, 
bhidder,  abdominal  wall,  internal  luMnorrhage,  etc.),  the  fractures 
themselves  generally  unite  with  little  difficulty.  The  pelvis  should 
be  innnobilized  by  a  broad  canvas  belt  or  strips  of  adhesive  plaster; 
and  it  often  is  well  to  secure  relaxation  of  the  adductors,  sartorius 
and  rectus  muscles  by  keeping  the  thighs  moderately  flexed.  Some 
disability  may  persist  from  shortening  of  one  lower  extremity,  due 
to  imperfect  replacement  of  the  fragments,  or  from  mol)ility  due  to 
diastasis  of  one  of  the  {)clvic  joints. 

Fracture  of  the  Acetabular  Rim  is  a  rare  injury  due  to  force  trans- 
mitted through  the  femur,  which  may  become  siil)luxated  upward 
and  backward.  The  diagnosis  is  difficult  without  a  skiagraph.  Treat- 
ment consists  in  applying  weight  extension  to  the  femur  in  the 
abducted  position,  after  replacing  the  head  in  its  socket,  and  main- 
taining this  position  for  three  or  four  weeks.  Use  of  the  limb  should 
not  be  allowed  for  ten  or  twelve  weeks  after  injury. 

Under  the  name  Central  Dislocation  of  the  Hip  is  described  a  stellate 
fracture  of  the  acetabulum  caused  by  the  head  of  the  femur  being 
driven  through  it  into  the  pelvis  by  direct  violence  acting  in  the 
axis  of  the  femoral  neck;  pregnancy  seems  to  be  a  predisposing  cause. 
Henschen  (1909)  has  collected  139  cases.  Skillern  (1911)  classifies 
the  lesions  as  "fractura  perforans"  and  "perforatum,"  according 
to  the  degree  of  intrapelvic  displacement.  The  diagnosis  is  made 
from  flattening  of  the  trochanter  and  relaxation  of  the  supratrochan- 
teric  structures;  by  palpating  the  luxated  head  in  the  pelvis  by  a 
finger  in  the  vagina  or  rectum;  and  by  recurrence  of  deformity,  with 
crepitus,  after  reduction.  The  intrapelvic  spicules  of  bone  should  not 
be  replaced  until  the  head  of  the  femur  has  been  withdrawn.  The 
thigh  should  be  dressed  in  plaster  of  Paris  in  a  flexed  and  adducted 
position,  and  the  patient  should  bear  no  weight  on  the  limb  for  two 
or  three  months. 

Fractures  of  the  Sacrum  and  Ischium  are  rare.  The  tuber  ischii 
has  been  detached  by  muscular  violence. 

Fractures  of  the  Coccyx  follow  falls  or  kicks  or  parturition,  and 
may  readily  be  diagnosed  by  inserting  the  index  finger  into  the 
rectum  and  grasping  the  coccyx  between  this  and  the  thumb,  when 
abnormal  mobility  and  perhaps  crepitus  will  be  detected.  If  forward 
displacement  is  persistent,  it  is  best  to  excise  the  occcyx  at  once, 
since  if  the  bone  unites  in  bad  position,  or  if  non-union  results,  there 
often  ensues  in  women  a  train  of  neurasthenic  symptoms  constituting 
the  affection  known  as  coccygodynia.  This  is  characterized  by  local 
pain,  interference  w4th  defecation,  vesical  irritability,  and  sometimes 
a  life  of  invalidism;  all  of  which  may  be  cured  by  removal  of  the 
entire  coccyx  at  the  sacrococcygeal  articulation. 


326 


FRACTURES 


FRACTURES  OF  THE  UPPER  EXTREMITY. 

Clavicle. — The   entire   upper   extremity   dei)eiuls   on   the   chivicle 
for  its  l)ony  connection  with  the  trunk,  and  this  bone,  therefore,  is 

exposed  to  all  manner  of  strains 
transmitted  from  the  periphery. 
The  patient  falls  on  the  hand,  or 
on  the  point  of  the  shoulder,  or 
rarely  receives  a  blow  directly  on 
the  clavicle,  which  gives  way  usually 
at  its  weakest  part,  between  the  at- 
tachments of  the  sterno-mastoid  and 
trapezius  on  its  upper  surface,  and 
those  of  the  pectoralis  major  and 
deltoid  on  its  lower  surface,  ap- 
proximately at  its  middle,  where 
the  two  curves  of  the  bone  meet. 
The  line  of  fracture  nearly  in- 
variably is  oblique  from  before 
backward  and  from  without  inward ; 
and  as  the  main  function  of  the 
bone  is  to  prop  the  shoulder  away 
from  the  trunk,  giving  the  humerus  a  greater  range  of  motion,  the 
main  deformity  consists  in  the  shoulder  falling  inward  and  forward, 


Fig.  297. — Deformity  from  fracture 
of  left  clavicle,  much  more  noticeable 
than  the  average  case.  Episcopal 
Hospital. 


Fig.  298. — Skiagraph  of  fracture  of  clavicle,  with  slight  comminution,  from 
direct  violence.    Age  twenty-three  years.     Episcopal  Hospital. 

toward  the  trunk,  by  contraction  of  the  muscles  of  the  axillary  folds, 
while  the  weight  of  the  upper  extremity  causes  sliglit  dropping  of 


FUM'Tl'RES  OF   Till':  CLAVKLK  '.Vll 

the  shouldtT.  'V\w  iimcr  ciul  of  tlic  claNicIc  rriiiiiiiis  in  its  normal 
position,  or  possibly  is  raist'd  a  little  hy  the  steriio-niastoid;  and  at 
the  outer  end  of  this  fraf^nient  a  depression  can  be  felt,  owing  to  the 
displacement  inward  and  backward  of  the  outer  fragment  (Figs.  297 
and  l2i)S).  In  rare  cases  this  presses  on  the  subclavian  vessels  or  the 
l)rachial  plexus,  but  in  the  vast  majority  of  cases  the  fracture  is  entirely 
uncomplicated.  Owing  to  the  inward  rotation  of  the  shoulder,  the 
vertebral  border  of  the  scapula  may  become  prominent.  The  diagnosis 
sometimes  isdifhcult  in  cases  of  green-stick  fracture,  and  in  fat,  chu})by 
children,  in  whom  the  outlines  of  the  bones  may  be  hard  to  detect; 
but  e\en  in  cases  where  deformity  is  absent,  there  will  be  persistent 
localized  tenderness  at  the  seat  of  fracture.  In  cases  with  deformity, 
the  diagnosis  is  easy,  even  the  attitude  of  the  patient  being  more  or 
less  characteristic;  he  carries  his  head  bent  toward  the  affected  side, 
su{)ports  the  injuretl  limb  with  his  other  hand,  and  is  unwilling  or 
unable  to  raise  the  arm  from  the  side. 

Fractvre  of  the  Outer  End  of  the  Clavicle,  a  much  rarer  injury, 
generally  is  due  to  direct  violence;  if  the  fracture  occurs  through  the 
coraco-clavicular  ligaments  there  is  little  displacement,  but  if  external 
to  them,  the  outer  fragment  is  carried  downw'ard  and  inward,  a 
displacement  which,  owing  to  the  posterior  convexity  of  the  curve 
at  this  point,  causes  the  inner  fragment  to  protrude  posteriorly,  and 
produces  a  characteristic  deformity. 

Treatment  of  Fractured  Clavicle. — Reduction  of  the  deformity  is 
difficult,  and  accurate  retention  of  the  fragments  nearly  impossible; 
nevertheless,  such  good  functional  results  follow  conservative  treat- 
ment that  operation  is  very  rarely  performed,  especially  as  a  scar 
would  be  more  conspicuous  than  the  moderate  amount  of  deformity 
which  usually  follows  conservative  treatment.  By  placing  the  patient 
fiat  on  the  back,  on  a  hard  bed,  and  with  a  folded  sheet  or  firm,  flat 
pillow  across  the  bodies  of  the  scapulfe,  this  will  act  as  a  fulcrum 
and  the  force  of  gravity  will  carry  the  shoulder  backward,  rotating 
the  outer  fragment  out  into  its  normal  relation  with  the  inner.  If 
now  a  small  bag  of  shot  were  placed  over  the  inner  fragment,  to 
press  it  down  against  the  outer,  and  the  head  raised  on  a  pillow 
to  relax  the  sterno-mastoid,  and  the  upper  extremity  immobilized 
by  proper  bandages;  and  if  the  patient  could  be  induced  to  remain 
in  this  position  for  tw^o  or  three  weeks  until  union  was  fairly  firm, 
then  recovery  without  deformity  probably  would  be  assured.  Cou- 
teaud  (1909)  induced  24  patients  to  submit  to  bed  treatment,  and 
secured  excellent  results  by  letting  the  arm  hang  down  over  the  side 
of  the  bed  for  the  first  two  days,  thus  approximating  the  fragments 
by  keeping  the  pectoralis  major  tense.  But  even  a  young  girl 
anxious  to  preserve  her  neck  from  trifling  deformity  rarely  will  endure 
such  confinement,  and  it  becomes  necessary  to  devise  some  means 
of  ambulatory  treatment;  and  though  by  such  treatment  entire 
absence  of  deformity  rarely  can  be  secured,  yet  recovery  of  function 
usually   is  perfect.      The   indications  are   to   keep  the   scapula  flat 


328 


FRACTURES 


against  the  chest,  thus  rotating  the  shoulder  and  outer  fragment 
away  from  the  chest;  to  steady  the  inner  fragment  by  a  compress; 


Fig.  29y. — Dressing  for  fracture  of  clav- 
icle: compress  over  inner  fragment;  arm 
in  Velpeau  position;  fold  of  elbow  and 
chest  protected  by  lint.  Episcopal  Hos- 
pital. 


Fig.  300. — Dressing  for  fracture  of 
clavicle:  arm  fixed  bj-  adhesive  plas- 
ter.   Episcopal  Hospital. 


and  to  support  the  weight  of  the  upper  extremity.  The  fact  that 
m^Tiad  dressings  have  been  devised  to  meet  these  points  suflBciently 
indicates  that  none  of  them  is  entirely  efficient.  In  children  a  pos- 
terior figure-of-eight  bandage  (Fig.  n9),  drawing  the  shoulders  back- 


3 

Fig.  301.^ — Dressing  for  fracture  of 
clavicle:  application  of  Velpeau  ban- 
dage.   Episcopal  Hospital. 


Fig.  302. — Dressing  for  fracture  of 
cla\'icle:  Velpeau  bandage  reinforced  by 
figure-of-eight  turns  around  elbow,  shoul- 
der and  axilla.     Episcopal  Hospital. 


ward,  with  a  compress  over  the  inner  fragment,  and  with  the  arm 
supported  in  a  sling,  usually  gives  very  satisfactory  results.    In  adults. 


FRACTURES  OF  THE  CLAVICLE 


329 


ill  whom  the  parts  arc  more  (hfficMilt  to  fix,  I  prefer  to  use  the  dressing 
indicated  in  the  aeeonii)anying  ilhistrations.  After  strap])ing  a  com- 
press over  the  inner  fragment,  and  fixing  the  sc;ii)ula  l)y  a  broad  stra|) 
of  adhesive  plaster  passing  across  tlie  back  to  the  axilla  of  the  sound 
side,  a  piece  of  lint  is  placed  in  the  elbow,  the  axilla  is  dusted  with 


Fig.  303. 


-Fracture  of  scapula  through  body  and  near  angle.     Age  twenty-four 
years.     Episcopal  Hospital. 


boric  acid  powder,  and  a  large  fold  of  lint  is  fastened  across  the  chest 
(Fig.  299) ;  the  arm  is  then  slung  to  the  chest  by  a  board  band  of 
adhesive  plaster  (Fig.  300) ;  a  Velpeau  bandage  is  then  applied,  fixing 
the  arm  to  the  chest  (Fig.  301);  this  is  reinforced  by  turns  of  the 
bandage   beneath  the  elbow,  crossing  each  other  over  the  injured 


330  FRACTURES 

shoulder,  and  passing  beneath  the  axilla  of  the  opposite  side  (Fig.  302). 
The  last  turns  support  the  upper  extremity  and  pull  the  inner  frag- 
ment down,  forming  a  valuable  addition  to  the  Velpeau  bandage.  This 
dressing  need  not  be  renewed  until  it  comes  loose — usually  not  for  six  or 
seven  days;  and  at  the  end  of  four  weeks  may  be  discontinued,  and 
the  arm  merely  carried  in  a  sling,  its  active  use  being  prohibited 
until  six  wTcks  from  the  time  of  the  accident.  Rarely  is  any  after- 
treatment  required,  normal  use  restoring  function  in  a  short  time. 

Scapula. — This  generally  is  broken  by  direct  violence.  Fractures  of 
the  body  of  the  scapula  (Fig.  303)  usually  are  more  or  less  transverse, 
and  the  fragments  are  not  much  separated:  but  by  fixing  the  angle 
with  one  hand,  and  manipulating  the  shoulder  with  the  other,  both 
crepitus  and  mobility  may  be  detected  in  most  cases.  Disability 
rarely  is  marked.  Treatment  consists  in  immobilizing  the  upper 
extremity  for  four  or  five  weeks.  Fractures  of  the  acromion  process 
are  more  frequent  than  those  of  the  body  of  the  bone,  and  are  to 
be  diagnosed  by  persistent  localized  tenderness  following  direct 
injury,  sometimes  by  crepitus,  but  rarely  by  distinct  mobility  unless 
the  line  of  fracture  is  distinctly  posterior  to  the  acromio-clavicular 
joint.  Skiagraphic  confirmation  is  desirable,  and  will  serve  to  dis- 
tinguish this  injury  from  separation  of  the  epiphysis,  which  probably 
is  a  more  frequent  injury,  but  clinically  indistinguishable  from  frac- 
ture. Immobilization  for  about  four  weeks  is  sufficient.  Fracture 
of  the  coracoid  process  may  occur  from  muscular  action,  or  rarely 
from  direct  violence.  It  is  a  rare  injury,  but  usually  may  be  detected 
by  painstaking  examination,  unless  the  patient  is  very  muscular  or 
fat.  The  process  is  pulled  downward  into  the  axilla  by  the  muscles 
attached  to  it,  and  often  may  be  felt  here,  while  it  is  absent  from  its 
normal  site  just  below  the  outer  third  of  the  clavicle.  If  crepitus 
cannot  be  obtained  in  confirmation  of  apparent  displacement  and 
mobility,  a  skiagraph  must  be  relied  on  for  diagnosis.  Fracture 
through  the  surgical  ueck  of  the  scapula,  the  line  of  fracture  passing 
through  the  suprascapular  notch  and  detaching  both  the  coracoid 
and  glenoid  processes,  is  a  rare  injury  which  may  be  mistaken  for 
dislocation  of  the  shoulder;  in  dislocation,  however,  the  arm  hangs 
away  from  the  side,  mobility  is  decreased  or  even  absent,  and  no 
crepitus  can  be  obtained;  in  fracture,  though  the  humerus  is  carried 
downward  and  inward  with  the  detached  fragment  by  the  pull  of 
the  axillary  muscles  and  those  attached  to  the  coracoid,  thus  pro- 
ducing a  hollow  beneath  the  acromion,  yet  attentive  examination 
will  show  that  there  is  in  the  axilla  not  the  isolated  head  of  the 
humerus,  but  a  bony  mass  composed  of  coracoid,  glenoid,  and 
humerus,  and  that  the  coracoid  moves  with  the  humerus  and  is 
detached  from  the  scapula.  Moreover,  there  is  crepitus  and  abnormal 
mobility;  and  when  the  deformity  is  reduced,  it  recurs  at  once;  none 
of  which  phenomena  are  present  in  dislocation.  Finally,  skiagraphic 
evidence  may  be  called  in  aid,  and  usually  w^ill  determine  the  matter 
without  doubt.     Treatment  consists  in  reducing  the  deformity  as 


FRAC.TVRKS  OF   THE  HUMERUS 


331 


far  MS  i)()ssil)l(\  n\n\  imiiu)l)ili/jiig  the  iij)ikt  extremity  as  in  fractures 
of  the  claxicU';  a  folded  towel  or  other  flat  support  should  he  ])laced 
in  tlie  axilla  to  aid  in  retaining  the  fragment  in  place,  {{eduction 
usually  is  imperfect,  callus  may  be  exuberant,  and  the  restoration 
of  function  may  be  much  delayed,  perhaps  from  involvement  of  the 
suprascapular  nerve.     . 

Humerus. — It  is  customary  to  divide  these  injuries  into  fractures 
of  the  upper  end,  those  of  the  shaft,  and  those  of  the  lower  end  of 
the  l)one. 


Fig.  304. — Fracture  of  anatomical  neck  of  humerus.     At;r  lill^  -Iniir  years. 
Episcopal  Hospital. 


Fractures  of  the  Upper  End  of  the  Humerus. — Fracture  of  the 
anatomical  neck  is  a  rare  injury;  the  detached  hemispherical  frag- 
ment is  wholly  or  largely  intra-articular,  and  is  displaced  tow^ard  the 
axilla,  turning  at  right  angles  to  the  shaft  (Fig.  304).  Sometimes 
the  fragment  is  forced  through  the  capsule  of  the  shoulder-joint,  and 
lies  almost  subcutaneously  in  the  axilla.  Palpation  then  detects 
the  head  in  its  abnormal  position,  while  the  tuberosities  retain  their 


332 


FRACTURES 


normal  relations  to  the  shaft  of  the  humerus  and  to  the  acromion. 
Crepitus  may  be  elicited  by  pressing  the  detached  head  outward 
against  the  shaft;  but  unless  the  head  is  clearly  palpable  a  positive 
diagnosis  is  very  difficult  without  a  skiagraph.  Most  cases  so  diag- 
nosed turn  out  to  be  high  fractures  of  the  surgical  neck.  If  the  head 
is  displaced  so  far  as  to  be  almost  subcutaneous,  it  is  best  to  remove 
it  by  incision;  function   will  be  much  better  than  if  the  fragment 


Fig.  305. — Separation  of  upper  opipliysis  of  humerus.  Typical  displacement.  _  Note 
pyramidal  shape  of  upper  end  of  diaphysis,  and  new  formed  bone  beneath  periosteal 
bridge  on  inner  side  of  fracture,  which  has  not  been  reduced.    Age  nine  years. 

remains  as  a  foreign  body  to  excite  periarthritis.  In  cases  where 
displacement  is  slight,  the  treatment  described  below  for  fracture 
of  the  surgical  neck  is  efficient.  Fracture  of  the  greater  tuberosity 
occasionally  occurs  from  muscular  action,  and  more  rarely  still  from 
direct  violence;  a  sprain  fracture  is  a  not  unusual  lesion  accompanying 
dislocation  of  the  shoulder.  The  fragment  is  drawn  outward,  upward, 
and  backward  by  the  external  rotator  muscles.  Reduction  may  be 
easy,  but  usually  is  very  difficult  to  maintain  even  if  the  humerus  is 


FRACTURES  OF  THE  HUMERUS 


333 


dressed  in  Jilxluetioii.  Ilenee  ojjerative  fixation  by  periosteal  suture 
of  ehroniie  eatf,nit  may  be  advisable.  In  other  cases,  firm  bandaf,'ing 
over  a  shoulder-eap  may  keep  the  frajiment  in  place.  Separation  of  the 
upper  epiphysis  of  the  hunienis:  This  epiphysis  may  be  separated  at 
any  age  until  it  unites  with  the  diaphysis,  not  later  than  twenty- 
five  years.  The  injury  is  commonest,  however,  at  or  a})out  fifteen 
years  of  age,  though  sometimes  it  occurs  as  an  o})stetrical  injury. 
The  upper  end  of  the  diaphysis  is  pyramidal  in  shape  (Fig.  305), 
and  the  epiphysis  fits  over  it  like  a  cap.  The  epiphyseal  line  passes 
on  the  surface  of  the  bone  just 
beneath  the  greater  tuberosity, 
irregularly  inward,  being  intra- 
articular on  the  inner  side  of  the 
humerus,  so  that  the  detached  frag- 
ment (the  epiphysis)  is  somewhat 
larger  than  that  in  fracture  of  the 
anatomical  neck,  but  smaller  than 
that  in  fracture  of  the  surgical  neck. 
The  displacement  of  the  epiphysis 
depends  largely  on  muscular  ac- 
tion: the  subscapularis  in  front  and 
the  infraspinatus  and  teres  minor 
behind  draw  the  epiphysis  directly 
inward,  while  the  supraspinatus, 
being  unopposed,  tilts  its  outer 
margin  (the  greater  tuberosity) 
upward;  the  diaphysis  usually,  but 
not  always,  is  drawn  inward  and 
forward,  by  the  muscles  of  the 
axillary  folds,  and  in  typical  cases 
is  prominent  beneath  the  anterior 
fibres  of  the  deltoid.  Fracture  of 
the  surgical  neck  of  the  humerus  is 
the  most  frequent  injury  of  the 
humerus  in  adults,  and  is  produced 
usually  by  a  fall  or  blow  on  the 
outer  surface  of  the  shoulder.  The 
region  included  in  the  surgical  neck 
is  that   from  the   epiphyseal  line 

above,  to  the  upper  border  of  the  insertions  of  the  pectoralis  and  teres 
major  muscles  below.  "High  fractures  of  the  surgical  neck,"  some- 
times called  "fractures  through  the  tuberosities,"  are  in  all  respects 
similar  to  epiphyseal  separations,  but  occur  after  ossification  in  the 
epiphyseal  line.  The  typical  displacement  in  ordinary  fracture  of  the 
surgical  neck  consists  in  the  lower  fragment  being  drawn  inward  by 
the  axillary  muscles,  and  somewhat  upward  by.  the  deltoid,  triceps, 
and  muscles  running  from  the  humerus  to  the  coracoid  process.  Unless 
impaction  is  present  the  diagnosis  is  not  difficult;  the  tuberosities  do 


Fig.  306. — Skiagraph  of  impacted 
fracture  of  surgical  neck  of  humerus, 
(See  Fig.  307.)     Episcopal  Hospital. 


•)0   1 

oo4 


FRACTURES 


not  rotate  with  the  shaft,  and  deformity,  mobihty,  and  crepitus  are 
easily  detected. 

Treatment  of  Frdciiircs  of  the  Uyper  Eiul  of  the  Humerus. — After 
washing  the  parts  in  alcohol,  a  modified  Fergusson's  dressing  (1842) 
is  applied  as  follows:  a  primary  roller  is  applied  from  the  metacarpus 
up  to  the  site  of  fracture,  with  the  elbow  flexed;  this  prevents  swelling 
of  the  hand  and  forearm  and  adds  much  to  the  patient's  comfort. 
The  fracture  is  then  reduced,  by  traction  downward  in  the  axis  of 
the  body,  manipulating  the  upper  end  of  the  shaft  so  as  to  pusli 


Fig.  307. — Impacted  fracture  of  surgical  neck  of  humerus  after  reduction  under 
an  anesthetic.     Compare  Fig.  306.     Episcopal  Hospital. 


it  out  and  l)ring  it  into  contact  with  the  u})i)er  fragment.  Then  a 
moulded  shoulder-cap  of  binder's-board,  well  padded,  is  placed  over 
the  shoulder,  reaching  almost  to  the  elbow,  and  is  held  in  place  by 
a  spica  bandage  of  the  shoulder  (see  Fig.  311).  A  sufficient  amount 
of  raw  cotton  is  then  placed  between  the  arm  and  chest  to  fill  up  the 
natural  hollow,  and  to  keep  the  shaft  of  the  humerus  from  being  dis- 
placed inward.  The  arm  is  then  bandaged  to  the  thorax,  and  a  sling 
is  applied  to  support  the  wrist.  By  leaving  the  elbow  unsupported, 
thus  gaining  the  advantage  of  extension  by  the  weight  of  the  limb, 


FRACTURES  OF  TIIF  HUMFRUS 


335 


tluTo  is  loss  (Iniiijor  of  displacement  of  the  fragments.    This  dressing 
should  be  renewed  about  twice  weekly  for  five  weeks.    1  have  never 


Fig. 


308. — Fracture  of  humerus  above  insertion  of  deltoid,  lower  fragment  displaced 
outward  and  upward  by  that  muscle.     Episcopal  Hospital. 


found  it  necessary  to  dress  the  arm  in  abduction  in  order  to  secure 
better  apposition  of  the  fragments. 


336 


FRACTURES 


In  cases  of  fracture  of  the  surgical  neck  impacted  with  deformity 
I  believe  it  usually  is  better,  except  in  the  very  old  or  feeble,  to 
anesthetize  the  patient,  free  the  impaction  (usually  easy)  by  forced 
rotation,  and  reduce  the  deformity  as  far  as  possible  (Figs,  306  and 
307). 

Fractures  of  the  Shaft  of  the  Humerus. — These  may  occur  at  any 
level,  usually  from  direct  violence,  but  occasionally  from  muscular 
action.     In  1906  I  found  references  to  96  such  cases,  mostly  due  to 


Fig.  309. — Fracture  of  lower  third  of  shaft  of  humerus.     Episcopal  Hospital. 


throwing  a  ball,  the  two  ends  of  the  humerus  apparently  being  twisted 
apart  by  violent  rotation  of  the  upper  end,  opposed  by  the  inertia  of 
the  rest  of  the  limb.  Fractures  from  direct  violence  are  more  apt 
to  be  transverse  and  comminuted,  than  those  caused  by  indirect  vio- 
lence, which  are  more  or  less  oblique  or  spiral.  If  the  fracture  is 
above  the  insertion  of  the  deltoid,  there  is  a  tendency  for  the  lower 
fragment  to  be  carried  up  and  out  by  this  muscle;  while  the  upper 
fragment  is  pulled  inward  by  the  axillary  muscles  (Fig.  3()<S);  but  if 
the   fracture    is   below   the   insertion   of  the   deltoid,   the    reverse    is 


FRACTURES  OF  THE  HUMERUS 


337 


Fig.  310. — Drpssitij;  for  fraoture  of  shaft  of 
humerus:  coaptation  splints  around  scat  of  frac- 
ture.    Episcopal  Hospital. 


the  case,  the  upper  fra<i;ment  l)einj,^  disphieed  outward  by  the  deltoid, 

while  the  lower  is  tlrawii  up  toward  the  axilhi  by  the  bieeps,  trieeps, 

and  coraco-braehialis.     In  fractures  of  the  hwer  third  of  the  shaft, 

which  are  rarer,  there  is  an^juhir  deformity  forwards,  owiujj;  to  the 

actiou  of  tiie  luuscles  arisin<i; 

from    the    condyles    of    the 

liumerus     which     keep     the 

elbow  flexed,  and  thus  brin<j; 

the  upper  end  of   the  lower 

fraj;inent  forward,  as  the  arm 

falls  by  the  side   (Fiji  :><>!)). 

Tn  all  fractures  of  the  shaft 

the  diagnosis  is  easily  mad(\ 

and  reduction  is  not  difficult 

to  secure  nor  to  maintain   if 

an  efficient  dressing  is  applied. 

That  which  I  have  used  with 

perfect  satisfaction  is  shown 

in    the    accompanying    illus- 
trations.     A    primary   roller 

is   applied   up  to  the  elbow; 

the    arm    is    surrounded    by 

raw  cotton;  three  coaptation 

splints  of  binder's-board  are 

adjusted  around  the    arm,  one   anteriorly,  one  posteriorly,  and  one 

externally  (Fig.  310),  and   are   secured  by    continuing  the  bandage 

up  to  the  axilla;  over   this   a  shoulder-cap   is   next  adjusted    (Fig. 

311),  and  fixed  by  a  spica  of  the   shoulder    (Fig.    312);  the  arm  is 

finally  bandaged  to  the  chest 
and  a  wrist  sling  applied 
leaving  the  elbow  unsup- 
ported to  give  extension  to 
the  seat  of  fracture  (Fig.  313). 
In  rare  cases  with  overlapping 
of  very  oblique  fractures, 
weight  extension  can  be  ap- 
plied as  an  ambulatory  dress- 
ing (F^ig.  314).  If  the  fracture 
is  in  the  lower  third  of  the 
humerus  an  anterior  angular 
splint  (Fig.  315)  may  be  used, 
either  alone,  or  in  addition 
to  the  use  of  a  shoulder-cap; 
but  in  fractures  above  this 
region  any  attempt  to  im- 
mobilize the  elbow  will  result 

in  transferring  every  motion  of  the  forearm  to  the  seat  of  fracture 

in  the  humerus,  and  delayed  union  frequently  will  result. 
22 


Fig.  311. — Dressing  for  fracture  of  shaft  of 
humerus:  shoulder-cap  applied.  Episcopal 
Hospital. 


338 


FRACTURES 


Fractures  of  the  Lower  End  of  the  Humerus. — These  are  much  more 
frequent  in  children  than  in  adults.     The  usual  cause  in  children 


Fig.  .312. — Dressing  for  fracture  of  shaft 
of  humerus,  shoukler-cap  secured  by 
spica  bandage  of  shoulder.  Episcopal 
Hospital. 


Fig.  .31.3. — Dressing  for  fracture  of 
shaft  of  humerus  completed  and  wrist 
sling  applied.     Episcopal  Hospital. 


is  a  fall  on  the  outstretched  hand;  in  adults  such  an  accident  is  more 
apt  to  cause  dislocation  if  the  lesion  occurs  at  the  elbow.      Direct 


Fi"G.  314. — Weight  extension  for  frac- 
ture of  shaft  of  humerus.  Episcopal 
Hospital. 


Fig.  31-5. — Anterior    angular  splint   applied 
to  elbow.     Episcopal  Hospital. 


injury,  often  resulting  in  compound  or  comminuted  fractures,  is  a 
more  frequent  cause  of  elbow  fractures  in  adults.    There  are  several 


FRACTURES  OF  THE  ICLBOW 


339 


distinct  types  of  Fracturt'  lioro,  which  may  he  conveniently  c 
thus  (PV  •^••'): 

1.  Sni)racoii(lyIar  I'Vactures  ^ 

2.  Diacondyhir   Fractures      ^  These  are  tlie  most  frequent  v 

3.  External  Condyle  J 

4.  Epiphyseal  Sei)aration. 

5.  Internal   Condyle. 

().  IntcTcondylar.  T  or  Y. 

7.  Ei)itrochlea. 

The  lower  epiphysis  of  the  humerus  is  de\elopcd  from  a 
of  centres,  and  is  l)est  studied  in  a  series  of  skia,<j;raphs  of 
elbows:  the  centre  iur  the  capitellum 
of  the  humerus  appears  during  the 
first  year  of  life,  that  for  the  head  of 
the  radius  becoming  visible  in  the 
sixth  year,  closely  followed  by  that 
for  the  epitrochlea  of  the  humerus. 
These  centres  are  well  shown  in  Fio;. 


assified 


arieties. 


number 
normal 


Fig.  316. — Diagram  to  show  classification  of 
fractures  of  the  lower  end  of  humerus. 


I'k;.  :517. — Skiagraph  showing  lower 
epiphysis  of  humerus  at  five  years 
and  eleven  months  (antero-posterior). 
Episcopal  Hospital. 


olT.  The  centre  for  the  trochlea  appears  at  eleven  years,  and  that 
for  the  olecranon  a  little  later.  Fig.  318  is  a  lateral  view  of  the 
normal  elbow  at  eleven  years. 

1.  Supracotuh/lar  Fractures  usually  are  due  to  a  fall  on  the  out- 
stretched hand,  the  elbow  being  suddenly  hyperextended,  and  the 
lower  end  of  the  humerus  torn  off  partly  by  ligamentous  distraction, 
partly  by  the  force  of  the  blow,  which  generally  displaces  the  fragment 
posteriorly.  The  line  of  fracture  is  oblique  from  abo\e  downward  and 
forward  (Fig.  319).  Impaction  is  unusual.  When  the  elbow  is  extended 
it  is  found  that  lateral  motion  is  possible  between  the  forearm  and 


340 


FRACTURES 


arm,  the  "carrying  angle"  is  lost,  antero-posterior  movements  give 
crepitus,  and  often  the  lower  end  of  the  npper  fragment  can  be  felt 


Fig.  318. — Skiagraph  of  lower  epiph.ysis  of  humerus  at  eleven  years  (lateral). 
Episcopal  Hospital. 


Fk 


319. — Skiagraph  of  supracondylar  fracture  of  humerus;  before  reduction, 
elbow  dressed  on  anterior  right-angled  splint.     Episcopal  Hospital. 


FRACTURED  OF  THE  ELBOW 


341 


ill  the  1)011(1  of  tlie  dhow.  Tlie  coiulylcs  retain  tlieir  normal  relation 
with  the  oleeranon,  which  is  not  the  ease  in  posterior  dislocation 
at  the  elbow,  for  which  the  deformity  of  fractnre  sometimes  is  mis- 
taken. 

2.  Diacoiid  1/1(1  r  Fractures  are  transverse  fractures  between  the 
level  of  supracondylar  fractures  and  that  of  the  epi})hyseal  line. 
They  usually  follow  a  fall  on  the  extensor  surface  of  the  forearm, 
the  elbow  being  flexed,  and  often  are  impacted.  The  line  of  fracture 
traverses  the  thin  layer  of  })one  separatin*^  the  olecranon  and  coro- 
noid  fossjK.     Diagnosis  is  based  on  the  history,  the  signs  of  elbow 


Fig.  320. — Supracondylar  fracture  of  humerus  shown  in  Fig.  319,  after  reduction 
dressed  in  position  of  hyperflexion.     Episcopal  Hospital. 


injury,  and  skiagraphic  examination.  A  rare  form  described  by 
Posadas  (1901)  consists  in  forward  displacement  of  the  lower  fragment 
and  posterior  dislocation  of  the  bones  of  the  forearm. 

3.  Fractures  of  the  External  Condyle  usually  follow  falls  on  the  out- 
stretched hand;  as  the  ulna  does  not  articulate  with  the  hand,  the 
force  is  transmitted  tlirough  the  radius  directly  to  the  external  con- 
dyle, thus  explaining  the  greater  rarity  of  fractures  of  the  internal 
condyle.  The  line  of  fracture  extends  into  the  joint,  somewhere 
between   the   capitellar   and   trochlear   surfaces    (Fig.    321);    lateral 


342 


FRACTURES 


mobility  usually  is  present,  and  crepitus  can  he  detected  either  in  this 
way  or  by  moving  the  external  condyle  with  thumb  and  finger  directlv 


Fiv,.  321. — Skiagraph  of  fracture  of  external  condyle  of  humerus. 

upon  the  shaft.     Under  the  name  epicondylitis,  ^lombtirg  (1910)  has 
described   what    corresponds    to    a    sprain-fracture   of   the   external 

epicondyle.  I  have  seen  several 
cases  appparently  of  this  nature. 
4.  Separation  of  the  Entire 
Lower  Epiphysis  may  occur  until 
its  union  with  the  diaphysis, 
from  fifteen  to  seventeen  years, 
but  usually  occurs  before  thirteen 
years  of  age.  The  epiphyseal 
line  is  largely  intra-articular,  pass- 
ing below  the  coronoid  fossa.  A 
small  shell  of  bone  often  is  de- 
tached from  the  diaphysis  also 
(Fig.  322) ;  if  this  is  not  the  case, 
and  the  line  of  fracture  passes 
directly  along  the  epiphyseal  line 
(cartilage),  it  will  not  be  visible 
in  a  skiagraph.  ^lany  epiphyseal 
separations  are  wrongly  classed  as 
mere  sprains,  because  the  skia- 
graph shows  nothing  abnormal. 
The  trauma  producing  the  injury 
...        .        often    is    slight,    and    deform it\' 

■i'SJ. — >kiagrai)h  ot  epiphyseal  ,       •  i  c    -i  ' 

separation  of  left  humerus.  rarely  IS  present ;    but  failure  to 


Fi( 


FRACTURES  OF  THE  El. HOW 


343 


recognize  tlic  lesion  may  l)e  disastrous.  The  diagnosis  is  based  on  a  his- 
tory of  injury,  on  indistinct,  nuifflcd  crepitus,  extreme  pain  on  forced 
extension  and  persistent  hx-aiized  tenderness  in  the  flexure  of  theelhow. 


Fk;.  323. — .Skiagraph  of  fracture  of  internal  condyle  of  humerus.     Episcopal 

Hospital. 

5.  Fractures  of  the  Internal  Condyle. — These  are  rare  in  children, 
but  being  caused  usually  by  direct  violence  (falls  on  the  acutely 
flexed  elbow)  are  relatively  more  frequent  in  adults.  The  usual 
line  of  fracture  is  shown  in  Fig.  323.  The  disability  is  extreme,  the 
support  of  the  ulna  being  destroyed:  the  forearm  falls  against  the 
side,  causing  loss  of  the  carrying  angle,  and  the  internal  condyle 
may  be  moved  antero-posteriorly  on  the  shaft. 

6.  Intercondylar  Fractures  are  very  rare,  especially  in  children. 
They  are  caused  by  great  violence,  almost  always  direct,  the  ulna 
being  driven  up  between  the  condyles  and  separating  them  from  each 
other  and  from  the  shaft  (Madelung),  resulting  in  a  Y-fracture;  or  the 
diaphysis  splitting  into  halves  the  fragment  due  to  a  supracondylar 
fracture  (Gurlt,  1862),  resulting  in  a  T-fracture.  The  diagnosis  rests 
on  the  independent  mobility  of  the  condyles  on  each  other  and  on 
the  shaft. 


344 


FRACTUEES 


7.  Fractures  of  the  Ejntrochlea  (Fig.  324)  often  are  epiphyseal  sepa- 
rations of  this  centre,  as  it  does  not  unite  witli  the  diaphysis  until  the 


Fig.  .324. — Skiagraph  of  fracture  of  epitrochlea  of  humerus.     Episcopal  Hospital. 

eighteenth  year.  The  injury  usually  is  due  to  muscular  or  ligament- 
ous action,  and  is  a  not  unusual  accompaniment  of  posterior  dislocation 
of  the  elbow. 


Fig.  325. — Fracture  of  capitellum  of  humerus,  from  fall  on  elbow.  Age  thirtj'-eight 
years.  Patient  under  care  of  Dr.  Jopson  in  University  Hospital.  Fragment  replaced 
by  arthrotomy.     Excellent  result. 

Of  other  rarer  fractures  of  the  lower  end  of  the  humerus,  those  of  the 
capitellum  (Fig.' 325)  are  of  most  importance;  the  fragment  usually 


FRACTURES  OF  THE  ELBOW 


345 


is  displaced  into  tlic  Ixnid  of  the  elbow,  and  seldom  can  be  replaced 
without  incision. 

Treatment  of  Fractures-  of  the  Lower  End  of  the  IIunieruff.—A^  these 
fractures  are  all  close  to  the  joint,  and  many  of  them  wholly  or  in 
part  intra-articular,  it  is  extremely  important  to  secure  early  and 
aecurat(>  reduction  of  the  frat^ments,  in  order  to  lessen  the  amount 
of  callus  formed,  and  thus  i)ermit  restoration  of  perfect  function. 
Intelligent  man(ruvres  of  reduction  can  l)e  undertaken  only  after 
a  correct  diagnosis  has  been  made,  and  1  have  dwelt  upon  the  indi- 
vidual lesions  so  fully  not  because  their  treatment  is  materially 
ditfcrent,  but  because  accurate 
reduction  must  be  secured  at  the 
earliest  possible  moment;  only  in 
this  way  can  surgeons  hope  to 
remove  the  oi)pr()l)rium  which  has 
long  attached  to  these  injuries  and 
which  1  believe  is  quite  unnecessary. 


a    - 


Fig.  32G. — Diagram  of  carrying  angle. 
(After  Potter.) 


Fig.  327. — Patient  shownng  normal 
carrying-angle  on  right  and  gunstock 
deformity  on  left.     Children's  Hospital. 


Supracondylar  fractures  form  the  large  proportion  of  these  injuries, 
and  I  shall  discuss  the  treatment  of  this  variety  at  greatest  length. 
The  muscles  arising  from  the  condyles  of  the  humerus  are  the  only 
muscles  attached  to  the  fragment,  and  they  tend  to  keep  it  flexed 
on  the  forearm.  Motion  transmitted  from  the  forearm  takes  place 
between  the  fragment  and  the  shaft  of  the  humerus,  not  in  the  elbow- 
joint.  The  fragment  usually  is  displaced  posteriorly.  All  these 
considerations,  as  well  as  clinical  experience,  teach  that  it  is  better 
to  dress  these  injuries  with  the  elbow  flexed.  The  fracture  is  reduced, 
by  hyperextension  of  the  elbow  to  relax  the  triceps,  then  by  extension 


346 


FRACTURES 


and  counter-extension  to  bring  the  fragment  forward  into  its  normal 
relation  with  the  shaft.  It  is  kept  reduced  by  hyperflexion  of  the 
elbow  (flexion  as  acute  as  possible),  thus  bringing  the  insertion  of  the 
triceps  anterior  to  the  humerus,  and  making  this  nuiscle  act  as  a 
sling  in  holding  the  fragment  in  place.  In  order  to  preserve  the 
"carrying  angle,"  which  is  formed  by  an  equal  obliquity  of  the 
articular  surfaces  of  the  humerus  and  the  bones  of  the  forearm  (Fig. 
326),  it  is  extremely  important  to  flex  the  forearm  upon  the  arm 
directly  in  the  sagittal  plane,  and  to  keep  it  in  that  position,  thus 
avoiding  internal  rotation  of  the  lower  fragment.     When  there  is 


Fig.  328. — Patient  showing  cubitus  valgus  after  recovery  from  fracture  of 
internal  condyle.     Episcopal  Hospital. 


loss  of  the  "carrying-angle"  (cubitus  varus,  Fig.  327)  the  forearm 
falls  to  the  outer  side  of  the  arm  when  the  elbow  is  hyperflexed. 
Increase  of  the  "carrying  angle"  (cubitus  valgus)  is  a  less  conspicuous 
and  much  less  disabling  deformity  (Fig.  32S). 

Other  fractures  of  the  lower  end  of  the  humerus  must  all  be 
reduced  accurately  by  suitable  manipulations,  which  cannot  be 
described  at  length  here.  All  may  be  kept  reduced  by  dressing  the 
elbow  in  hyperflexion.  The  method  in  which  this  is  to  be  done  is 
sufficiently  indicated  in  the  accompanying  illustrations:  the  arm 
and  forearm  act  as  splints  to  each  other,  and  when  they  are  bound 
to  each  other  they  may  be  rotated  inward  as  one  bone,  and  the  hand 
slung  around  the  neck  (Figs.  329,  330,  331).     The  elbow  is  dressed 


rnACTURKS  OF   THE  KLIiOW 


347 


Fig.  329. — Dressing  to  maintain  elbow  in  hyi)rrflexion,  first  static.   Ei)iscopal  Hospital. 


Fig.  330. — Dressing  to  maintain  elbow  Fig.  331. — Dressing  to  maintain  elbow 

in  hyperflexion,   second  stage.    Episcopal.        in  hyperflexion,    completed.     Episcopal 
Hospital.  Hospital. 


348 


FRACTURES 


about  twice  weekly,  the  hyperflexion  being  reduced  at  each  dressing 
only  enough  to  permit  washing  the  flexure  of  the  elbow,  and  re-inser- 
tion of  a  fold  of  lint.  At  the  end  of  the  second  week  the  elbow  may 
be  dressed  in  less  acute  flexion,  and  at  the  end  of  four  weeks  may  be 
carried  in  a  sling  for  a  week  or  ten  days.  No  massage  or  passive 
motion  is  necessary  to  restore  function  if  accurate  reduction  has 
been  secured;  but  full  extension  may  not  be  secured  for  several 
months. 

Ulna. — Fractures  of  this  bone  are  caused  mostly  by  direct  violence. 
Fractiires  of  the  olecranon,  however,  may  occur  from  muscular  action 
in  sudden  flexion,  or  as  a  "compression"  fracture  in  hyperextension 
of  the  elbow;  unless  the  aponeurotic  insertion  of  the  triceps  is  torn 
widely  there  is  not  much  separation,  but  mobility  and  crepitus  usually 
are  distinct.  In  simple  fractures  operation  rarely  is  indicated,  as 
by  strap})ing  the  fragment  on  to  an  obtuse  angled  splint  (Fig.  332) 
reduction  usually  is  easy;  even  if  accurate  reduction  is  not  secured 


Fig.  332. — Dressing  fracture  of  olecranon  on  anterior  obtuse  angled  splint.     Padding 
omitted  to  show  splint  better.    Episcopal  Hospital. 


at  the  first  attempt,  it  is  remarkable  how  much  imp^o^•ement  in 
position  is  obtained  in  a  few  days.  This  is  one  of  the  few  fractures 
which  prove  an  exception  to  the  general  rule  that  prompt  reduction 
is  necessary  for  recovery  of  good  function.  In  compound  fractures, 
operation  is  preferable  (Figs.  333  and  334).  Separation  of  the  olecranon 
epiphysis,  which  appears  first  in  a  skiagraph  from  ten  to  eleven  years, 
is  a  rare  injury,  requiring  the  same  treatment  as  fracture.  Fracture 
of  the  coronoid  process  is  a  rare  accompaniment  of  posterior  dis- 
location of  the  elbow,  and  is  to  be  suspected  when  it  is  diflScult  to 
maintain  reduction  of  this  lesion.  The  fragment,  which  is  partly 
intra-articular,  and  which  has  the  brachialis  anticus  attached  only  to 
its  base,  seldom  is  much  displaced.  Treatment  consists  in  dressing 
the  elbow  in  hyperflexion  for  a  couple  of  weeks,  and  then  allowing 
gradual  extension.  Fractures  of  the  shaft  of  the  ulna  are  very  dis- 
abling, as  the  ulna  forms  the  main  part  of  the  elbow-joint,  and  through 
the  interosseous  ligament  supports  the  radius  and  hand.     Patients 


FRACTURES  OF  THE   ULNA 


349 


wltli  fracture  of  tlu>  ulna  rarely  can  hold  the  forearm  out  for  an 
examination  without  sui)i)ort  from  the  other  hand.  In  the  ui)i)er 
part  of  the  shaft  the  displacement  often  is  backward,  owing  to  the 


Fig.  333. — Skiagraph  of  compound  fracture  of  olecranon.     Treated  by  operation. 
(See  Fig.  334.)     Episcopal  Hospital. 

pull  of  the  triceps  (Fig.  33(3) ;  but  when  the  trauma  has  been  great, 
the  ulna  may  be  displaced  anteriorly,  the  continuation  of  the  force 
causing  forward  dislocation  of  the  head  of  the  radius  (Fig.  406).  In 
the  lower  part  of  the  shaft,  the  pronator  quadratus  draws  the  lower 


Fig.  334. — Skiagraph  of  compound  fracture  of  olecranon,  after  suture  of  aponeurosis 
of  triceps  with  chromic  catgut.    Age  twenty-five  years.     Episcopal  Hospital. 

fragment  against  the  radius,  producing  a  deformity  very  difficult  to 
overcome,  though  sometimes  extreme  abduction  of  the  hand,  by  the 
use  of  a  reverse  Bond  splint   (one  made  for  the  other  hand),  may 


350 


FRACTURES 


succeed  (Skillern,  1910).  Green-dick  fractures  of  the  uhin  are  frcHjuent, 
but  these,  as  well  as  complete  breaks  of  the  middle  and  lower  thirds, 
are  frequently  accompanied  by  fracture  of  the  radius.  Fracture 
of  the  styloid  process  of  the  ulna  often  accompanies  fractures  of  the 
lower  end  of  the  radius. 

Owing  to  the  subcutaneous  position  of  the  ulna  the  diagnosis  of 
these   various   fractures   presents   few  difficulties;   and   all   may   be 

treated  by  immobilizing  the  fore- 
arm on  a  straight  splint,  with 
pads  so  adjusted  as  to  o\ercome 
the  tendency  to  displacement. 

Radius. — Fractures  of  the  head 
of  the  radius  usually  are  caused 
by  a  fall  on  the  over-extended 
]:)alm,  the  force  transmitted 
through  the  radius  making  it 
impinge  with  great  force  on  the 
external  condyle,  and  splitting 
the  head  of  the  radius  into  two 
or  more  parts  (Fig.  335).  The 
symptoms  are  persistent  localized 
pain  and  tenderness,  indistinct 
crepitus  on  rotation,  but  rarely 
appreciable  mobility  or  displace- 
ment. A  skiagraph  usually  is 
necessary  for  confirmation,  but 
unless  several  are  taken  in  differ- 
ent planes,  the  line  of  fracture 
may  not  be  visible.  If  there  is 
a  loose  fragment  it  is  better  to 
excise  it,  as  non-union  is  frequent. 
In  most  cases,  however,  it  is 
sufficient  to  immobilize  the  fore- 
arm for  about  four  weeks  in  fnll 
supination  on  an  anterior  angular 
splint  (Fig.  315).  Fractures  of  the 
neck  of  the  radius  result  from  much 
the  same  causes  as  those  of  its  head,  but  may  accompany  fractures 
of  the  olecranon  from  a  fall  on  the  flexed  forearm;  or  may  be  accom- 
panied by  a  fracture  of  the  shaft  of  the  ulna  (Fig.  336).  These 
fractures  are  apt  to  be  impacted,  and  it  is  not  desirable  to  disturb 
the  impaction  lest  non-union  result,  the  upper  fragment  being  so 
small  as  to  be  uncontrollable.  The  forearm  should  be  dressed  in  full 
supination.  Fractures  of  the  shaft  of  the  radius  are  unusual  except 
when  accompanied  by  fracture  of  the  ulna.  If  the  fracture  is  above 
the  insertion  of  the  pronator  radii  teres,  this  muscle  will  pronate  the 
lower  fragment  while  the  upper  will  be  supinated  and  flexed  by  the 
biceps;  to  reduce  the  deformity  the  forearm  should  be  dressed  in  full 


Fig.  335. — Fracture  of   head  of   radius. 
Age  twenty-six  years.     Episcopal  Hospital. 


FRAl'TURI'JS  OF  THE  RADIUS 


351 


supination  (Lonsdale,  KS;JS),  on  an  anterior  splint,  with  the  elhow 
flexed.  If  the  fraeture  oecurs  below  the  insertion  of  the  pronator 
radii  teres  this  nuiscle  will  keep  the  ui)per  fragment  senii-pronated, 
and  the  lower  fragment  should  he  brought  into  that  position  before 
the  splint  is  applied,  and  so  dressed. 


Fig.  330. 


-Fracture  of  neck  of  radius  complicating  fracture  of  upi)er  half  of 
ulna.     Episcopal  Hospital. 


Fmriurcs  of  the  Lower  End  of  the  Radius.— The  typical^  fracture 
in  this  region,  one  of  the  most  frequent  in  the  entire  body,  is  known 
by  the  name  of  Colles  (1814).  Colles's  Fracture  results  almost  invari- 
ably from  a  fall  on  the  over-extended  palm,  and  the  break  occurs 
about  1  or  2  cm.  above  the  wrist-joint;  the  lower  fragment  is  dis- 
placed toward  the  extensor  surface,  often  being  impacted  into  the 
posterior  surface  of  the   shaft,   the  lower  end   of  which  protrudes 


Fig.  337. — Colles's  fracture  of  radius,  showing  silver-fork  deformity;  recent 
accident  in  patient  of  sixteen  years.     Episcopal  Hospital. 

beneath  the  flexor  tendons.  This  typical  displacement  is  known  as 
the  "silver-fork  deformity,"  and  Fig.  337  shows  that  it  is  well  merited; 
often,  how^ever,  deformity  is  much  less  evident.  In  addition  to  the 
antero-posterior  displacement  (Fig.  338),  there  usually  is  moderate 
radial  deviation  of  the  hand,  rendering  the  head  of  the  ulna  promi- 
nent (Fig.  339).  A  fracture  of  the  ulnar  styloid  is  a  frequent 
accompaniment.     Crepitus  and  mobility  seldom  are  present,  and  the 


352 


FRACTURES 


diagnosis  usually  is  made  from  the  deformity  and  localized  pain 
and  tenderness;  but  even  in  cases  without  visible  deformity  the 
lesion  should  be  suspected  from  the 'nature  of  the  injury.  If  un- 
recognized as  a  recent  injury  the  deformity  may  become  much  more 
evident  in  the  next  twenty-four  hours,  and  the  patient  and  the  surgeon 
whom  he  consults  then,  are  apt  to  blame  one  who  failed  to  recognize 
a  fracture  the  dav  before.     Treatment  consists  in  reduction  as  soon 


Fig.  33S.  —  Skiagraph  (lateral 
view)  of  unreduced  CoUes's  fracture 
of  radius,  slight  silver-fork  deform- 
i'.y;  duration  three  weeks.  (See 
Fig.   339.)      Episcopal    Hospital 


Fig.  339. — Skiagraph  (antero-posterior  view) 
of  unreduced  Collcs's  radial  fracture  of  radius, 
with  displacement  of  lower  fragment,  and 
fracture  of  the  styloid  process  of  the  ulna.  (See 
Fig.  338.)     Episcopal  Hospital. 


as  possible  after  the  injury  (Fig.  340) :  this  is  accomplished  by  hyperex- 
tension  and  forced  adduction  of  the  lower  fragment  (Fig.  341),  followed 
by  direct  pressure  forward  on  it,  with  counter-pressure  backward  on 
the  lower  end  of  the  upper  fragment.  If  impaction  is  very  firm,  an 
anesthetic  maybe  required.  Usually  more  force  is  necessary  even  in 
cases  of  slight  impaction  than  the  inexperienced  surgeon  expects;  and 
though  failure  to  secure  accurate  reduction  may  not  materially 
interfere   with  use  of  the  hand,  some   deformity   will  remain,   and 


FRACTURES  OF  THE  RADIUS 


353 


ill   many  cases  tlir   hand   is  iKTnianently   weakoncd.     Any  drossinj; 
which  will   hold   the   l"ra<,Mncnts  in  i)hK'c  may  then   he  appHed,   the 


Fig.  340. — Skiagraph  of  recent  Colles's  fracture  of  radius  and  fracture  of  styloid 
process  of  ulna,  after  reduction.     Episcopal  Hospital. 

forearm  being  in  semi-pronation  or  full  supination,  never  in  complete 
pronation.      Supination    is   the    movement   which   is   most   difficult 


Fig.  .341. — Reduction  of  Colles's  fracture,  of  left  radius.     Episcopal  Hospital. 

to  regain,  and  if  the  hand  is  dressed  in  pronation,  it  may  never  be 
regained;  whereas  if  the  fracture  is  put  up  in  full  supination,  all 


354  FRACTURES 

subsequent  activities  of  the  hand  will  be  such  as  to  encourage  return 
of  pronation.  In  cases  where  no  tendency  exists  for  recurrence  of  dis- 
placement, a  straight  posterior  splint  (Tig.  342 j  makes  a  comfortable 


Fig.  34:2. — -Posterior  splint  for  Colles's  fracture.    Padding  omitted  for  photograph. 

Episcopal  Hospital. 

dressing;  for  the  first  week  this  should  extend  to  the  proximal  inter- 
phalangeal  joints,  but  may  then  be  shortened  to  the  metacarpo- 
phalangeal  articulation^.      In   cases   where  reduction   is   difficult   to 


Fig.  .343. — Bond's  splint. 

maintain.  I  prefer  to  use  a  Bond  splint  CFig.  343),  on  the  flexor 
surface,  with  two  compresses,  one  on  the  dorsal  surface  over  the  lower 
fragment,  and  the  other  on  the  flexor,  to  fill  up  the  natural  concavity 


Fig.  344. — Bond  splint  for  Colles's  fracture.  Padding  omitted  from  splint,  and 
leather  guard  removed  to  show  compresses;  note  their  form  and  position.  Episcopal 
Hospital. 

of  the  forearm  above  the  wrist,  and  to  retain  the  upper  fragment  in 
proper  position  (Fig.  344).  Splint  support  should  be  continued  for 
four  weeks. 


FRACTURES  OF   THE  FOREARM 


355 


Other  FraHiiirs  of  the  Lower  End  of  the,  Radius. — Barton's  Fracture 
(1838)  is  tlu'  name  ijivcn  to  (letuchineiit  of  the  dorsal  portion  of  tlie 
articular  surfacr  of  the  radius;  diagnosis  without  a  skiaj^^raph  is 
difficult.  Reverfied  Colle.s's  Fracture,  in  which  the  lower  fragment  is 
displaced  toward  the  flexor  surface,  was  described  in  1865  by  Cal- 
lender;  the  displacement  was  named  "gardener's  spade  deformitx"  by 
Roberts  (1897).  Chauffeur's  Fracture,  so  named  because  often  received 
while  "cranking"  an  automobile,  may  be  of  various  types,  the  most 
frequent  of  which  is  one  splitting  off  the  outer  surface  of  the  articular 
surface  of  the  radius  through  the  base  of  the  styloid  process  (Fig.  345). 
Separation  of  the  lower  radial  epiphysis  (Fig.  28(ij  can  be  certainly 
distinguished  from  Colles's  fracture  only  by  radiograpli>-.  All  these 
lesions  should  be  treated  by  reduction  of  deformity,  when  present, 
and  immobilization  for  about  four  weeks. 


Fig.  .34.5. — "Chauffeur's  fracture"  of  lower  end  of  radius,  caused  by  kick  of  handle 
while  cranking.  Line  of  fracture  emphasized  in  retouching  skiagraph.  Orthopaedic 
Hospital. 


Both  Bones  of  the  Forearm. — These  fractures  are  frequent,  either 
from  a  fall  on  the  hand,  or  from  direct  violence.  The  forearm  is 
the  most  frequent  site  of  green-stick  fractures;  the  deformity  usually 
is  very  apparent  (Fig.  34(j),  and  the  treatment  consists  in  reducing 
this,  which  usually  involves  making  the  fracture  complete ;  but  as  this 
frequently  is  accomplished  without  much  rupture  of  the  periosteum, 
there  is  little  or  no  tendency  for  the  fragments  to  be  displaced 
subsequently.  The  forearm  is  dressed  as  in  complete  fractures.  In 
these  the  radius  usuallv  is  broken  a  little  higher  than  the  ulna,  and  one 


356 


FRACTURES 


or  both  bones  may  be  comminuted  (Figs.  347  and  34S).    The  diagnosis 
is  easy,  ovs'ing  to  the  extreme  mobility.    Reduction  should  be  attempted 


Fig.  346. — Green-stick  fracture  of  both  bones  of  forearm  one  month  after  injun,-  which 
was  untreated.     Reduced  under  anesthetic.     Children's  Hospital. 


by  fully  supinating  the  forearm,  and  making  extension  and  counter- 
extension  so  as  to  overcome  any  overlapping.     Correct  replacement 


Figs.  3-17  and  348. — Skiagraphs  of  comminuted  fracture  of  both  bones  of  forearm ; 
delayed  union  at  end  of  ten  weeks.  Patient,  aged  fifty-three  years,  then  returned  to 
work  as  blacksmith,  and  two  months  later  union-was  firm.    Episcopal  Hospital. 

of  the  ulnar  fracture  usually  can  be  determined  clinically,  as  this 
bone  is  subcutaneous;  Init  the  radius  is  buried  among  so  many  muscles 


FRACTCRES  OF   THE  FOREARM 


357 


tliat  a   skia^'rapli   frrf|iUMitly   is   necessary  to  ascertain   the   position 
of  the  t'ra'Mnents   if  the   fracture  is  al)()ve  the  middle  of  the  hone. 


^Fk;.  349.— Dressing  for  fracture  of  both  bones  of  forearm.     Padding  oniitt(;d.     Note 
length  of  splints.     Forearm  in  full  supination.     Episcopal  Hospital. 


Fig.  .350. — Skiagraph  of  fracture  of 
both  bones  of  forearm,  before  reduc- 
tion; lateral  view,  in  mid-pronation. 
Age  nine  years.  (See  Figs.  351,  352, 
353.)    Episcopal  Hospital. 


Fig.  351. — Skiagraph  of  fracture  of  both 
bones  of  forearm,  before  reduction;  antero- 
posterior view.  (See  Fig.  350.)  Episcopal 
Hospital. 


The  forearm  is  then  dressed  in  fvll  supinatwn  between  two  straight 
splints,  that  on  the  flexor  surface  extending  from  the  bend  of  the 


3oS 


FRACTURES 


elbow  to  the  tips  of  the  fintrers,  while  the  dorsal  splint  extends  from 
the  olecranon  to  the  wrist  (Fig.  349).  These  splints  should  be  a  little 
wider  than  the  forearm,  so  as  to  prevent  crowding  the  bones  together 
laterally,  and  they  should  be  smoothly  but  thickly  padded.  Apply 
the  spliiits  with  the  elbow  flexed  to  a  right  angle,  and  make  sure  that 
the  palmar  splint  does  not  compress  the  veins  in  the  bend  of  the 
elbow.     A  longitudinal  pad  placed  between  the  bones,  in  the  eft'ort 


Fig.  352. — Skiagraph  of  fracture  of  both 
bones  of  forearm  after  reduction.  Antero- 
po.sterior  view,  in  full  supination.  Same  case 
as  Figs.  350  and  351.     Episcopal  Hospital. 


Fig.  353. — Skiagraph  of  fracture  of 
both  bones  of  forearm  after  "reduc- 
tion." Recovery  with  perfect  func- 
tions and  no  palpable  deformity.  Epis- 
copal Hospital. 


to  wedge  them  apart  is  not  only  useless  but  harmful.  Extra  com- 
presses, however,  may  well  be  placed  over  any  of  the  fragments  that 
tend  to  project.  The  splints  are  then  strapped  snugly  around  the 
forearm  and  held  securely  in  place  by  a  roller  bandage.  A  large 
"handkerchief"  or  "triangular"  sling  is  applied,  and  the  forearm 
carried  against  the  chest,  but  always  in  full  supination.  I  urge  the 
employment  of  this  position  not  only  because  supination  is  the  most 
difficult  part  of  rotation  to  regain,  and  because  the  upper  fragment 


FRACTURES  OF  THE  ('ARFVS 


359 


of  the  radius  usually  is  kept  in  supination  by  the  biceps,  but  because 
I  lia\e  found,  if  the  forearm  is  ilressed  in  niid-pronation,  as  is  com- 
monly ad\iscd  now,  that  the  fraj^ments  saj^  by  the  force  of  gravity, 
and  the  j)aticnt  recovers  not  only  with  lost  sui)ination,  but  with 
angular  deformity  of  both  bones  toward  the  ulnar  side.  If  attempt 
is  made  to  correct  this  deformity  by  adjusting  a  coa{)tation  splint 
over  the  angular  projection  of  the  ulna,  this  may  be  overcome,  Init 
the  surgeon  will  succeed  merely  in  forcing  the  ulna  nearer  the  radius, 
which  camiot  be  influenced  by  such  an  appliance,  and  the  disability 
as  regards  rotation  will  be  increased.  It  often  is  exceedingly  difficult 
to  keep  these  fractures  even  approximately  reduced  during  the 
first  week;  but  usually  a  little  better  position  can  be  secured  at  each 


Fig.  3.54. — .Skiagraph  of  fracture  of  carpal  scaphoid.     Compare  with  normal 
wrist  in  Fig.  3.5.5.     Episcopal  Hospital. 


dressing,  and  when  the  ends  of  the  bones  begin  to  become  sticky, 
during  the  second  week,  it  will  be  found  that  deformity  daily  becomes 
less,  and  what  looked  at  first  like  a  hopeless  case,  will  result  in  a  very 
useful  arm,  and  one  with  slight  or  no  visible  deformity.  Skiagraphs 
are  valuable  and  interesting,  but  I  advise  the  inexperienced  not  to 
be  terrified  by  the  appearance  of  the  bones  in  a  skiagraph  into  think- 
ing that  only  operative  treatment  can  give  his  patient  a  good  result. 
If  he  uses  the  eyes  in  the  ends  of  his  fingers,  he  will  secure  by  con- 
servative means  quite  as  good,  and  in  many  cases  a  much  better 
result  than  by  operation,  and  in  a  shorter  time  (Figs.  350,  351,  352, 
and  353). 

Carpus. — Of  these  fractures,  that  of  the  scaphoid  is  least  unusual, 
resulting  usually  from  a  fall  on  the  thenar  eminence;  the  diagnosis 


360 


FRACTURES 


is  made  from  tenderness  in  the  "anatomical  snuffbox,"  sometimes 
l)y  dorsal  displacement  of  one  of  the  fragments,  and  effusion  in  the 


Fig.  355. — Skiagraph  of  normal  wri.st.     Compare  with  Fig.  u.Ji.     Episcopal 

Hospital. 

radio-carpal  joint.    Confirmation  by  a  skiagraph  is  advisable  (Figs. 
354  and  355).     Treatment  consists  in  excision  of  an  irreducible  frag- 


FiG.  356. — Dressing  for  fracture  of  metacarpals.     Hand  bandaged  over  a  roller. 
Episcopal  Hospital. 

ment,  and  in  immobilization  on  a  palmar  splint  for  three  or  four  weeks 
for  those  cases  without  deformity. 


FRACTURES  OF  THE  METACARPUS 


361 


Metacarpus.  Fractiirrs  of  the  metacarpals  result  usually  from 
(lirrct  violence  (pri/c-fiKlitinj,',  etc.);  the  (lisi)laeement  is  au^nilar, 
toward  the  extensor  surface,  and  may  he  difhcult  to  keep  reduced. 


Fig.  .357. — Fracture  of  base  of  thumb  metacarpal.     Episcopal  Hospital. 

The  hand  may  be  dressed  on  a  palmar  splint,  the  palm  being  well 
padded;  or  may  be  bandaged  over  a  firm  roller,  the  tension  on  the 


Fig.  358. — Dressing  for  fracture  of  the  phalanges.     Episcopal  Hospital. 

extensor  tendons  preventing  deformity  (Figs.  350) .  Fracture  of  the  base 
of  the  tJmmb  metacarpal  (Bennett,  1886),  may  resemble  a  subluxation 
of  that  bone  (Fig.  357). 


362  FRACTURES 

Phalanges. — Fractures  of  these  usually  are  caused  by  direct 
violence,  often  being  compound  and  requiring  amputation.  Simple 
fractures  are  dressed  on  antero-posterior  splints  (Fig.  358)  for  about 
three  weeks.  If  angular  deformity  toward  the  flexor  surface  persists, 
due  to  the  pull  of  the  interossei,  Stimson  (1907j  advises  dressing 
the  fingers  in  flexion  over  a  roller  bandage. 

FRACTURES  OF  THE  LOWER  EXTREMITY. 

Femur. — This  is  the  most  serious  fracture  of  the  extremities  that  a 
patient  can  suffer,  but  fortunately  it  is  less  serious  in  children,  in 
whom  it  is  more  frequent,  than  in  adults.  In  adults  fractures  of 
the  leg  are  much  more  frequent  than  in  children.  The  fractures  of 
the  femur  may  be  grouped  into  those  of  the  upper  end,  those  of  the 
shaft,  and  those  of  the  lower  end. 


Fig.  3.59. — Fracture  of  neck  of  femur  close  to  its  head.     Episcopal  Hospital. 

Fractures  of  the  Upper  End  of  the  Femur. — Fractures  of  the  neck 
of  the  femur  ("fracture  of  the  hip")  are  more  common  in  adults, 
especially  those  past  sixty-five  years  of  age,  than  in  children.  The 
trauma  in  the  aged  often  is  trivial  as  their  bones  are  more  brittle; 
some  cases  are  caused  by  a  mere  twist  of  the  leg,  catching  it  in  a 


FHACTUJiES  OF  THE  FEMUR 


363 


fold  of  tlu'  cariH't,  on  an  uneven  paving'  stone,  etc.,  or  by  sitting  down 
suddenly.  Such  injuries  usuall\  produce  a  fracture  of  the  neck  close  to 
the  head  (intracapsular),  and  seldom  are  iui[)acted  (Fig.  iiolJ).  Falls 
on  the  great  trochanter,  especially  in  ])atients  under  seventy  years  of 
age,  are  more  apt  to  result  in  an  impacted  fracture  close  to  the  trochan- 
ter (Fig.  ;)()()),  which  is  at  least  partly  extracapsular.  In  children, 
also,  fractures  of  the  neck  of  the  femur  usually  are  impacted,  or 
partial;  or  an  epiphyseal  separation  of  the  head  may  occur.  In 
impacted  fractures,  the  impaction  occurs  chiefly  at  the  expense  of 
the  posterior  i)art  of  the  neck,  the  shaft  of  the  femur  being  rotated 
outward  as  the  posterior  margins  of  the  fragments  are  driven  together. 


Fig.  360. — Impacted  fracture  at  base  of  neck  of  femur.     Age  sixty-five  years. 
Note  also  coxa  vara.     Episcopal  Hospital. 

Symptoms. — ]\Iuscular  spasm  is  prominent,  and  this,  with  local- 
ized pain  and  tenderness,  sometimes  are  alone  sufficient  to  warrant 
the  diagnosis  in  the  aged.  In  unimpacted  fractures  the  patient 
usually  is  unable  to  raise  the  limb  from  the  bed;  deformity  is  char- 
acteristic, consisting  in  eversion  of  the  lower  extremity,  the  fibular 
side  of  the  foot  lying  on  the  bed;  and  there  is  moderate  shortening 
(2  to  4  cm.),  which  frequently  increases  during  the  second  day.     In 


364 


FRACTURES 


impacted  fractures  the  shortening  may  not  exceed  1  cm.  Normally 
when  the  thigh  is  flexed  the  great  trochanter  lies  on  a  line  drawn 
from  the  anterior  superior  spine  of  the  ilium  to  the  tuber  ischii 
(Xelatons  line,  1847);  but  when  there  is  fracture  of  the  neck  of  the 
femur  the  muscles  (ilio-psoas,  adductors,  hamstrings,  glutei)  passing 
from  the  pelvis  to  the  shaft  pull  the  lower  fragment  up,  so  that  the 
trochanter  lies  above  this  line,  and  approaches  or  even  ascends  above 
a  plumb  line  dropped  from  the  anterior  superior  spine  when  the  patient 
is  lying  supine  i  Bryanfs  line,  lS79j;  the  relation  of  the  trochanter  to 
Xelaton's  and  Bryant's  lines  on  the  two  sides  should  be  compared  (Figs. 
361  and  362).  The  trochanter  is  less  prominent  on  the  injured  side 
owing  to  the  loss  of  support  from  the  neck  of  the  bone,  and  by  placing 
the  tips  of  the  fingers  between  the  trochanter  and  iliac  crest  it  will 
be  found  that  the  fascia  lata  on  the  injured  side  is  relaxed  (Allis's 
sign,  1877).  Sometimes  from  the  shortening  a  fold  or  wrinkle  is 
formed  over  the  tendo  patella,  and  can  be  smoothed  out  by  making 


Fig.  361. — Xelaton's  line:  passes  from 
anterior  superior  spine  of  ilium  to  tuber 
ischii  and  crosses  tip  of  great  trochanter 
of  femur,  when  thigh  is  partly  flexed. 


Fig.  362. — Bryant's  line,  a  plumb  line 
from  anterior  superior  spine  of  ilium, 
patient  supine.     Orthopaedic  Hospital. 


extension  (Cleemann,  1876).  In  cases  without  impaction,  mobility 
is  present:  tliis  may  be  detected  by  rotating  the  entire  limb,  when 
it  will  be  found  to  have  a  greater  range  of  motion  than  the  uninjured 
limb;  and  by  pushing  upward  and  pulling  downward  in  the  axis 
of  the  limb,  the  greater  trochanter  will  be  found  to  .slide  up  and 
down  on  the  pelvis.  During  these  manoeuvres  crepitus  usually  is 
elicited.  By  palpating  the  trochanter  as  the  limb  is  rotated,  it  will 
be  found  to  rotate  in  the  arc  of  a  smaller  circle  than  the  trochanter 
on  the  uninjured  side;  this  is  because  the  centre  of  motion  is  trans- 
ferred from  the  acetabulum  to  the  seat  of  fracture.  Usually  there  is 
an  abnormal  fulness  over  the  head  of  the  femur  (just  below  Poupart's 
ligament,  beneath  or  immediately  external  to  the  femoral  artery) 
owing  to  effusion  in  the  joint  and  the  external  rotation  of  the  outer 
fragment. 

Diagnosis  rarely  is  difficult  in  the  adult,  attention  being  paid 
to  the  history  of  injury,  even  if  slight,  and  to  the  cardinal  physical 
signs,  shortening,  eversion,  and  crepitus.     In  cases  with  impaction. 


FRACTURES  OF  THE  FEMl'R  3Go 

wliere  in()l)ility  and  crepitus  are  al)sont.  and  wlicrc  evcrsioii  and 
sli()rt(Miin<!;  are  sliij;lit,  the  diaifiiosis  is  less  certain;  hut  tiie  cautious 
surjieou  will  treat  all  suspected  injuries  of  the  hip  in  the  aged  as  if 
they  were  fractures  until  the  contrary  is  proved.  The  impaction 
may  he  slight,  and  is  apt  to  })e  released  spontaneously.  A  skiagraph  is 
very  useful  in  such  cases,  and  as  well  in  children,  in  whom  green-stick 
fracture,  epiphyseal  separation,  or  fracture  with  impaction,  are  the 
usual  lesions.  PVequently  the  true  nature  of  the  case  is  not  recognized 
in  children,  and  the  surgeon  sees  the  patient  first  when  traumatic 
cu.ra  vara  (p.  i)i'3)  has  developed. 

Prognosis. — In  the  aged,  death  occurs  from  shock,  pneumonia, 
l)ed-sores,  exhaustion,  etc.,  in  ahout  one  out  of  four  cases  during 
the  first  year  after  injury;  in  those  who  recover,  a  useful  limb  results 
in  ahout  GO  per  cent,  of  cases;  nearly  all  of  these  will  have  a  limp 
and  slight  eversion  (Ashhurst  and  Newell,  1908).  In  children  there 
is  little  disability  though  marked  degrees  of  coxa  vara  may  require 
subsequent  treatment. 

Treatment. — In  the  aged,  constitutional  treatment  often  is  more 
important  than  the  local;  these  patients  should  not  he  kept  in  bed 
after  the  first  shock  of  the  accident  and  the  acutest  symptoms  have 
subsided,  unless  the}'  continue  to  improve.  Get  them  up  in  a  chair 
a  few  hours  each  day  so  soon  as  they  seem  to  be  losing  ground.  Watch 
for  and  guard  against  hypostatic  congestion  of  the  lungs  and  bed- 
sores. Keep  the  bowels  open  and  the  kidneys  active.  Stimulate 
the  appetite. 

The  usual  teaching  is  not  to  disturb  an  impaction  if  one  is  present; 
and  a  very  good  rule  it  is  in  almost  all  cases;  hut  in  children  this  does 
not  hold  good  if  there  is  deformity,  and  in  such  cases  even  in  young 
adults  (even  up  to  forty-eight  years),  it  is  a  question  whether  a  more 
useful  limb  might  not  be  secured  by  breaking  up  the  impaction 
and  dressing  the  limb  in  extreme  abduction  as  described  below. 
Impaction  is  rare  except  in  fractures  near  the  trochanters,  and  non- 
union would  not  be  apt  to  occur  if  the  impaction  were  reduced  in 
vigorous  adults.  But  in  aged  persons,  or  speaking  generally,  in  those 
past  sixty  years,  it  is  far  better  to  let  the  fracture  stay  impacted, 
even  if  there  is  deformity,  since  it  is  better  to  have  them  walking 
about  with  a  limp  and  shortening  and  eversion,  than  to  have  them 
dependent  on  crutches  or  even  a  cane,  as  is  almost  always  the  case 
if  non-union  is  present.  Cotton  suggested  in  (1910)  producing  arti- 
ficial impaction  in  recent  fractures  by  hammering  on  the  trochanter 
with  a  mallet,  and  has  practised  this  method  with  success  in  a 
number  of  cases. 

Unimpacted  fractures  may  be  reduced  by  flexing  the  thigh  on 
the  pelvis  to  a  right  angle  (to  relax  the  iliopsoas  which  may  press 
the  capsule  between  the  fragments),  then  making  vertical  traction 
upward  on  the  thigh,  and  finally  bringing  the  thigh  down  to  the  plane 
of  the  bed  in  moderate  internal  rotation  and  abduction  as  great  as 
possible.     This  last   manoeuvre   makes  the  anterior  portion  of  the 


366 


FRACTURES 


capsule  tense,  and  wedges  the  outer  fragment  against  the  detached 
head  lying  loose  in  the  acetabulum  by  causing  the  great  trochanter 
to  impinge  on  the  posterior  lip  of  the  acetabulum,  and  by  keeping 

the  iliopsoas  tense  across  the 
anterior  part  of  the  joint.  Whit- 
man, who  since  1904  has  ad- 
vocated the  abduction  treatment 
of  fractures  of  the  femoral  neck, 
encases  the  entire  lower  extrem- 
ity and  pelvis  in  plaster  of  Paris 
(Fig.  oOo) ;  but  this  is  not  always 
well  borne  by  old  people,  in 
whom  it  often  is  better  to  use 
the  ordinary  Buck's  extension 
apparatus  (Fig.  364),  using 
enough  weight  (8  to  12  pounds) 
to  prevent  muscular  spasm.  The 
position  of  abduction  may  be 
encouraged  by  fastening  the 
pelvis  to  the  opposite  side  of 
the  bed.  However,  it  is  very 
difficult  to  maintain  sufficient 
abduction  without  a  gypsum 
splint,  and  in  all  adult  patients  I 
prefer  the  method  of  lateral  and 
longitudiiml  traction,  which  in- 
variably has  given  me  better 
results.  This  was  described  accurately  in  1869  by  Phillips,  was  taught 
for  many  years  by  Maxwell,  and  has  been  revived,  systematized,  and 


Fig.  363. — Abduction  cast  for  separation 
of  epiphysis  of  head  of  femur;  age  fourteen 
years.  Cast  has  been  cut  off  foot  recently 
to  facilitate  walking.     Episcopal  Hospital. 


Fig.  364. — Applying  Buck's  adhesive  plaster  extension  apparatus  for  fracture  of  femur. 

Orthopaedic  Hospital. 

popularized,  by  Rvith  (1899).  The  fracture  is  reduced  as  described 
above,  and  in  addition  to  the  longitudinal  extension  lateral  traction 
also  is  made   on   the   upper  part   of   the   thigh.     The   longitudinal 


FRACTURES  OF  THE  FEMUR 


367 


traction  sliould  bo  stronj;;  enoiiffli  to  overcome  sliorteniiig,  and  al)out 
two-thirds  as  niiicli  \veitj;lit  should  l)e  used  in  hiterai  traction  (Fi^-  •>•>•"))• 
The  lateral  traction,  which  should  draw  the   femur   slij^ditly    away 


Fig.  365. — Longitudinal  and  lateral  traction  for  fracture  of  neck  of  femur.  No(n 
also  use  of  Volkmann's  sliding  foot  splint  to  prevent  rotation  of  limb.  Episcopal 
Hospital. 


Fig.  366. — Fracture  through  trochanter.s  (if  femur;  rare  and  atypical  line  of  fracture. 

Episcopal  Hospital. 


368 


FRACTURES 


from  the  plane  of  the  bed  as  well  as  laterally,  overcomes  eversion 
and  keeps  the  capsule  of  the  hip-joint  tense,  preventing  it  from 
falling  in  between  the  fragments.  Every  two  or  three  days  the 
longitudinal  traction  should  be  substituted  by  traction  with  the 
hands  upon  the  thigh,  and  the  knee  should  be  flexed  gently  through 
about  30  degrees  to  prevent  stiffness.  Union  is  good  at  the  end  of 
four  weeks.  Ruth  found  in  1907  that  among  a  total  of  72  cases 
treated  by  this  method  there  had  been  no  failure  of  union  in  patients 
under  eighty  years,  no  failure  to  secure  a  useful  limb  under  seventy 
years  of  age,  and  in  those  past  eighty  years  of  age  success  was  obtained 
in  over  60  per  cent,  of  cases.  Impacted  fractures  are  treated  in  the 
same  way,  but  less  weight  is  required. 

Fractures  through  the  trochanters  of  the  femur  are  not  very  rare, 
usually  are  due  to  great  direct  violence,  and  often  are  impacted. 

Three  grades  of  this  injury  may  be 
recognized  (Ashhurst,  1913):  the  first  is 
little  more  than  an  impacted  fracture 
at  the  base  of  the  neck;  in  the  next,  the 
neck  penetrates  the  trochanteric  region 
further,  and  a  splitting  fracture  occurs; 
and  in  the  severest  grade  the  trochanteric 
region  is  entirely  shattered.  A  linear 
fracture  between  the  level  of  the  trochan- 
ters is  quite  rare  (Fig.  366).  In  most 
cases  the  lesser  trochanter  is  fractured 
(Fig.  367).  Binet  and  Hamant  (1911) 
have  collected  eight  cases  of  isolated  frac- 
ture of  the  lesser  trochanter.  Isolated 
fracture  of  the  great  trochanter  occurs,  and 
may  require  periosteal  suture  to  maintain 
reduction. 

Fractures  of  the  Shaft  of  the  Femur. — 
These  are  much  more  common  in  children 
and  young  adults  than  in  old  people, 
and  usually  are  due  to  direct  violence. 
There  are  three  main  types:  (1)  Fracture 
heloiv  the  trochanters.  The  upper  fragment  is  flexed  by  the  iliopsoas; 
and  rotated  outward  by  the  gluteus  maximus  and  the  short  external 
rotators.  The  lower  end  of  the  upper  fragment  often  is  felt  as  a  sharp 
projection  in  Scarpa's  triangle;  while  the  lower  fragment  is  drawn 
upward  and  inward  by  the  adductors  (Fig.  368).  The  leg  rolls  out- 
ward from  its  own  weight,  and  shortening  is  marked.  Crepitus  and 
abnormal  mobility  are  easily  detected.  (2)  Fracture  of  the  middle  of  the 
shaft,  often  oblique  (Fig.  272),  is  attended  by  more  shortening  than 
any  fracture  in  the  body,  sometimes  as  much  as  12  cm.  (five  inches); 
the  leg  rolls  outward,  there  is  flail-like  motion  and  marked  crepitus 
at  the  seat  of  fracture;  the  lower  fragment  is  drawn  up  and  in  by  the 
adductors  and  hamstrings,  and  the  upper  fragment  projects  anteriorly 


Fig.  367. — A  common  type  of 
fracture  through  the  trochanters: 
fracture  at  base  of  neck  of  femur 
(impacted) ;  with  separation  of 
lesser  trochanter.  Age  forty-five 
years.     Episcopal  Hospital. 


FliACTUliES  OF  THE  FEMUR 


369 


(Fi^.  'M\\)).  (o)  SiiprdroiKJi/htrfrdcturcs  are  cliaractori/od  ])y  i)()sterior 
(lisi)la(riiu'iit  of  tlio  lower  tragmeiit  wliieh  is  kept  flexed  at  the  knee 
by  the  ^astroeiiemiiis  (Fig.  -iTl);  and  hy  anterior  projeetion  of  the 
upper  fragment,  wiiieh  may  be  embedded  in  the  reetus  musele.  The 
diagnosis  of  these  ^■arious  types  of  fraetnre  of  the  shaft  is  not  difficult, 
since  the  displacement  is  fairly  constant,  and  if  deformity  is  great  the 
ends  of  the  fragnuMits  ustiall>  can  i)e  ])alpate(l  even  in  \ery  nuiseular 
limbs. 


Fig.  368. — Fracture  of  femur  below  trochanters.    Episcopal  Hospital. 


Prognosift. — The  general  mortality  is  about  15  per  cent.;  90  per  cent, 
of  those  who  recover  under  conservative  treatment  secure  entirely 
useful  limbs,  but  about  one  out  of  three  of  these  will  have  a  limp, 
and  only  about  one  patient  out  of  four  will  have  no  shortening  (Ash- 
hurst  and  Newell,  1908).  Though  many  surgeons  urge  the  operative 
treatment  of  recent  fractures  of  the  femur  as  a  routine,  I  am  not 
aw^are  that  they  have  published  figures  demonstrating  even  as  good 
results  as  the  above. 

Treatment. — Reduction  of  the  fracture  is  difficult,  but  probably 
could  be  more  often  obtained  if  the  patient  was  anesthetized.  Weight 
24 


370 


FRACTURES 


extension  should  be  applied  in  sufficient  amount  to  overcome  shorten- 
ing. Ochsner  has  found  that  if  the  adhesive  plaster  is  carried  up  to 
the  groin,  irrespective  of  the  height  of  the  fracture,  weight  extension 
is  much  more  efficacious.  I'he  full  amount  of  weight  necessary 
should  be  applied  during  the  first  day  or  two  after  the  accident, 
since  shortening  becomes  more  difficult  to  overcome  the  longer  it  lasts. 
By  raising  the  foot  of  the  bed  from  four  to  six  inches,  counter-exten- 
sion is  provided  by  the  weight  of  the  patient's  body.     If  necessary 


Fig.  369. — Pkiapraph  of  traiisvcrso 
fracture  of  shaft  of  femur.  Best  po!<i- 
tiou  ol)tainal)le  after  etherization  and 
attempts  at  reduetion  with  extension 
bv  ooinpound  pulley.  Femur  plated. 
(See  Fig.  370.)  Ago  twenty-three 
years.     Episcopal  Hospital. 


Fig.  370. — Skiagraph  of  patient  shown  in 
Fig.  309,  three  months  after  fracture  of  femur 
was  plated.  Excellent  result,  with  scarcely 
appreciaiiie  limitation  of  motion.  Episcopal 
Hospital. 


the  patient  is  anesthetized  (usually  on  the  second  day)  and,  short- 
ening being  overcome  by  the  weights,  the  fragments  are  manipu- 
lated into  as  accurate  apposition  as  possible.  Extension  by  means 
of  the  compound  pulley  may  be  necessary  in  very  muscular  adults, 
the  extension  being  made  by  means  of  a  clove  hitch  applied  above  the 
knee  (Fig.  372).     Sometimes  angulation  of  the  fragments  over  the 


FRACTURES  OF  THE  FEMUR 


forearm  will  enable  the  surgeon  to  secure  end-to-end  apposition. 
Absolute  reposition  rarely  can  be  obtained,  and  is  not  necessary 
to  secure  a  useful  limb.  In 
subtrochanteric  fractures  it  may 
be  necessary  to  raise  tiie  lower 
fragment  on  a  double-inclined 
plane,  in  order  to  ai)i)roximate 
it  to  the  upi)er  (Fig.  37.'));  and 
in  supracondylar  fractures  it 
always  is  a(hisable  to  flex  the 
knee  (rarely  to  divide  the  tendo 
Achillis)  so  as  to  relax  the  gas- 
trocnemius muscle.  In  fracture 
of  the  middle  of  the  shaft  the 
thigh  is  dressed  in  the  extended 
position,  and  the  seat  of  fracture 
always  should  be  supported  by 
coaptation  splints.  Rotation 
outward  of  the  lower  fragment 
is  prevented  by  the  use  of  \'olk- 
mann's  sliding  splint  (1882)  or 
similar  device  (Fig.  3()5).  A 
long  external  splint  (Liston, 
1837),  well  padded,  extending 
from  the  axilla  to  below  the 
foot,  and  bandaged  firmly  to 
the  entire  lower  extremity  and 
pelvis,  will  prevent  outward 
angulation  of  the  fracture;  and 

the   use   of   a  shot  bag  will   over-  ^ig.  371.-Skiagraph    of    fracture    above 

come  anterior  displacement.       In      pond^  Ics  of  femur.     Lower  fragment  drawn 

I'll  TT        -li       '         !•    j./io/'M\       baelcward  by  aetion  of  gastrocnemius.    Epis- 

children, Hamilton  ssplmt(  1850)     copal  Hospital. 


Fig.  372. — Clove  hitch  and  compound  pulley  for  reduction  of  fractures  of  the  femur 
under  anesthesia.  Counter-extension  by  a  sheet  tied  to  the  head  of  the  bed.  Episcopal 
Hospital. 


372 


FRACTURES 


facilitates  moving  the  patient,  as  it  fixes  both  lower  extremities  by 
long  external  splints  fastened  together  by  a  cross-bar  below  the  feet, 
through  which  passes  the  cord  carrying  the  weight  extension.  Im- 
mobilization in  adults  should  be  continued  for  six  to  eight  weeks, 
but  after  the  first  four  weeks  very  light  massage  is  permissible, 
above  and  below  the  fracture.  Weight-bearing  should  not  be  at- 
tempted for  eight  or  ten  weeks  after  the  injury — in  general,  not  until 
four  weeks  after  union  seems  solid,  as  subsequent  shortening  with 
angular  deformity  is  a  sad  consequence  of  too  early  efi'orts  to  walk. 
In  very  young  children  weight-bearing  may  be  resumed  in  six  or  seven 
weeks. 


Fig.  373- — Double  inclined  plane,  with  weight  extension  for  fracture  of  femur 
below  the  lesser  trochanter.     Episcopal  Hospital. 


Fractures  of  the  Lower  End  of  the  Femur. — Epiphyseal  separation 
occurs  oftenest  from  six  to  ten  years  of  age,  usually  from  hyper- 
extension  or  a  twisting  injury,  as  from  having  the  leg  caught  in  a 
revolving  wheel.  The  epiphysis  usually  is  displaced  forward  (Fig. 
374).  Reduction  may  be  difficult,  and  is  best  maintained  by  dressing 
the  knee  in  flexion.  Fracture  of  one  or  other  condyle,  usually  the 
external,  is  more  frequent  in  children  than  adults,  and  occurs  mostly 
from  direct  violence.  There  is  mobility  of  the  fragment,  and  lateral 
mobility  in  the  knee,  in  addition  to  crepitus,  localized  pain,  etc. 
Effusion,  perhaps  bloody,  often  occurs  into  the  joint.  Treatment 
consists  in  immobilization  with  weight-extension  or  plaster  cast, 
in  good  position,  for  four  or  five  weeks.  Use  of  the  limb  should  be 
gradually  resumed. 

Patella. — If  these  fractures  occur  from  direct  violence  there  may 
be  comminution,  but  there  seldom  is  much  separation  of  the  frag- 
ments unless  the  lateral  expansions  of  the  quadriceps  tendon  are 
ruptured;  in  fracture  from  muscular  action,  however,  which  is  the 


i'ir\cTi'ia<:s  of  v///-;  I'atklla 


373 


usual  loriu,  this  librous  cxpuiisiou  is 
takes  place  by  sudden  flexion  of  tlie  k 
l)reaks  the  patella  o\(t  the  condyh's 
as  an  o\-er-h(Mit  U'\'er.  The  hone 
nsuahy  <fi\-es  way  more  or  less 
trans\-ersely,  the  lower  frafjnicnt 
l)ein<;  smaller. 

Diagnosis.  -  l)iaji;nosis  is  easy, 
owinu,-  to  separation  between  the 
trajjnu'nts,  free  mobility,  and  crepi- 
tus. If  the  quadriceps  expansion  is 
not  torn,  the  j)atient  may  still  be 
able  to  walk;  usually  he  is  entirely 
disabled.  I  have  seen,  however, 
two  cases  of  subperiosteal  fracture, 
denionstratefl  by  skia^raplis,  in 
which   there  was   no  disability. 

Treatment.  —  Treatment  in  most 
cases  is  operative,  as  it  is  difficult 
to  secure  good  apposition  without 
suture  of  the  fragments.  But  in  the 
aged,  or  those  with  visceral  disease, 
operation  is  much  more  of  a  risk, 
and  conservative  treatment  may  se- 
cure a  very  useful  leg.  The  limb  is 
dressed  on  an  inclined  plane  (Fig. 
375),  thus  relaxing  the  quadriceps 
muscle,  and  the  fragments  are  ap- 
proximated by  straps  of  adhesive 
plaster,  much  as  in  the  case  of  frac- 
tured olecranon;  the  plaster  should 
be  readjusted  every  couple  days  to 


widely   torn,   as  the   fracture 
nee,  and  the  tense  quadriceps 


Fig.  374. — Separation  of  lower  epi- 
physis of  femur.  Reduced  under  ether 
and  knee  dressed  in  flexion  on  double 
inclined   plane.      Dr.   H.    C".   Deaver's 

ciise.      Episcopal    Hospital. 


Fig.  375. — Fracture  of  patella,  dressed  un  inclined  plane.     Episcopal  Hospital 


374 


FRACrrRES 


keep  tlie  fraf^ments  as  dose  together  as  possible,  and  to  avoid  everting 
tliem.     'J'his  dressing  is  eontinufd  for  six  weeks.     Even  if  onlv  fif>rous 


Fio.  376.— Fracture  of  patella  with  wide  separation  of  fraj^ments,  showing  power  of  full 
extension  six  years  after  injury.     No  operation  was  done.     Episcopal  Hospital. 

union  results,  and  if  after  getting  about  the  bond  of  union  stretches,  as 
it  frequently  does,  the  power  of  extension  of  the  knee  may  f>e  retained 


Fig.  .'i77. — ltn<:ynr<:  of  j^at'-lla  \,ii'ti'-  '-(/'/.ition.     Age  twenty-eight  years. 
Episcopal  Hospital. 

(Tig.  370j;  but  in  almost  all  cases  there  will  be  slight  limp,  and  some 
disability  in  gc>irig  up  stairs.    Ojjeration  is  best  done  between  the  fifth 


I'liACrVUKH  OF   Till':   IWTKLLA 


375 


iiiid  tent  li  (lays  jit'lcr  iiijiifv  ;  cjirlicr  iii(cr\ ciil  imi  ^(»Ill(•t  iiiics  is  lollowcd 
l).\  iiilcct  ion,  <-iii(l  inrcctioii  in  w  kiu'c-jointor  this  kind  nsniilly  r('(|iiir('S 
iinipiitiitidii,  ;iiid  may  rcsiiM  in  the  pjiticiit's  dcMlli.  Tlic  inortidily 
ot"  ojMTJition  ex  (Ml  inidcr  the  l>rst  conditions  ni;iy  rc;icli  I  |)(r  cent. 
(Iv  (1.  Alexander,  Mill).  The  slrielest  aseptic  teehni(|ne  is  inipeni- 
tive.  A  seniihuiar  llap  is  turned  (h)\vM  or  up,  ex|)osin^'  the  seat  of 
fracture.  The  knee-joint  is  widely  o])ene(l,  and  clots  are  removed 
by  forceps  or  sponuini;'  with  moist  \i,\\\\/.v.  Any  frinjics  of  the  (piadri- 
cops  aj)oueurosis  turned   down   hetweeu   the   fra^nncnls  are  everted, 


Fig.  378. — •Fracfurc  of  piitdl.-i  riftcr  siidirc  willi  r'litoiiiic  cattiut.      I'lpi.scdpal  Hospital. 


and  two  holes  are  drilled  in  each  fra^ineiit,  from  the  superficial  to 
the  fractured  surface,  not  in\'adinjf  the  articular  surface  of  the  patella. 
The  fragments  are  then  sutured  with  a  mattress  suture  of  heavy 
chromic  catgut  or  wire;  the  quadriceps  expansion  and  capsule  are 
sutured  with  chromic  gut;  and  the  skin  with  interrupted  silkworm 
gut  (Figs.  'Ml  and  'MX).  In  some  cases  it  is  suflicient  to  suture  the 
fibrous  tissues  alone,  without  direct  suture  of  the  bone  (Blake,  Gibbon, 
1904).  If  all  oozing  has  been  checked,  and  the  skin  is  not  sutured  too 
tightly,  it  is  not  necessary  to  drain  the  wound;  otherwise  a  small  drain 


376 


FRACTURES 


should  be  left  for  forty-eight  hours.  The  limb  is  dressed  on  a  posterior 
splint,  which  may  be  removed  in  a  few  days  and  the  limb  laid  on  a 
pillow,  with  the  knee  slightly  flexed.  Most  surgeons  now  recommend 
l)eginning  very  gentle  passive  motion  four  or  five  days  after  operation, 
bv  raising  the  knee  a  few  inches  from  the  pillow  once  daily.  Xo 
active  motion  should  be  allowed  for  at  least  two  weeks,  and  not  then 
unless  the  bone  has  been  sutured  with  wire.  If  wire  has  been  used, 
the  fragments  depend  on  it  for  their  apposition  and  not  on  the  newly 
formed  callus.  True  bony  union  seldom  results,  and  if  absorbable 
bone  sutures  have  been  used,  the  knee  should  be  supported  by  a 
posterior  gypsum  splint,  or  light  brace,  to  prevent  excessive  flexion, 
for  eight  weeks  or  more  after  operation.  With  non-absorbable  suture 
the  patient  may  begin  to  walk  without  support  in  three  or  four  weeks. 
If  wire  has  been  used  it  may  require  to  be  removed.  Ilefracture  is 
not  verv  rare. 


Fig.  379.- 


^kiag^aph  of  partial  separation  of  upper  epiphysis  of  tibia. 
(Schlatter's  disease.)     Episcopal  Hospital. 


Tibia. — These  fractures  frequently  are  caused  ])y  direct  violence, 
except  those  of  spiral  type  following  twists  of  the  foot,  and  those 
of  the  internal  malleolus  accompanying  fracture  of  the  lower  end  of 


FRACTURES  OF  THE  T/IilA 


377 


the  fil)iila.  The  suhcutaneous  position  of  tlie  tibia,  aiul  the  fact 
that  it  sujiports  the  main  weight  of  tlie  body,  render  it  mnch  more 
liahlc  to  i!ijiir\-  than  the  fibula,  fractures  of  tlie  shaft  of  whicli  rarely 
occur  except  as  secondary  lesions  in  fractures  of  the  tibia.  The 
fractures  from  direct  violence  often  are  compound  or  comminuted. 

Fmcturcs  of  Ihc  upper  end  of  the  tibia  fretjuently  run  into  the  knee- 
joint  (Fig-  -~^').  !•"<!  s•^•novitis  may  result;  as  the  fracture  may   be 

subi)eriosteal     or    impacted,    involve-  

ment  of  the  knee-joint  with  pain  and 
tenderness  over  the  head  of  the  tibia, 
should  make  one  suspect  such  a  frac- 
ture. ( 'omplete  sepaniiion  of  the  upper 
epiphysis  of  the  tibia  is  rare,  but  "  start- 
ing of  the  epiphysis,"  sometimes  known 
as  Schlatter's  disease  (1903),  is  a  not 
infre(iuent  accompaniment  of  sprains 
of  the  knee  in  adolescents;  the  tibial 
tubercle,  which  forms  part  of  the 
epiphysis,  is  partially  lessened  by  the 
pull  of  the  tendo  patella^,  and  peri- 
osteal thickening  results  (Fig.  379). 
Most  cases  resemble  "sprain-frac- 
tures" (p.  298),  but  in  some  the  tibial 
tubercle  is  broken  loose  and  is  pal- 
pable as  a  distinct  fragment.  Treat- 
ment consists  in  rest  until  acute 
symptoms  subside;  immobilization  of 
the  knee  should  be  continued  for 
several  weeks. 

Fraetures  of  the  shaft  of  the  tibia  gen- 
erally are  oblique,  and  deformity  may 
be  great,  owing  to  the  pull  of  the  calf 
muscles  on  the  foot  which  causes 
shortening,  and  angular  projection 
forward  of  the  upper  fragment.  If 
this  is  pointed,  as  it  usually  is,  there 
is  danger  of  its  causing  a  slough  in  the 
skin  (Fig.  380).  There  also  is  a  ten- 
dency to  external  rotation  of  the  upper 
fragment  from  the  weight  of  the  thigh. 
Owing  to  the  deformity,  mobility,  and 
crepitus,  diacpiosis  is  easy.  The  fibula 
very  frequently  is  broken  also.  Treatment  consists  in  reduction  of  the 
deformity  by  extension,  counter-extension,  and  manipulation;  it  may 
be  assisted  by  placing  the  leg  in  Pott's  position  (1771) — lying  on 
its  fibular  side  with  the  knee  flexed  nearly  to  a  right  angle.  Where 
posterior  displacement  of  the  lower  fragment  is  very  persistent,  it 
may  be  advisable  to  divide  the  tendo  Achillis.    The  leg  may  be  put 


Fig.  380. — Skiagraph  of  fracture 
of  both  bones  of  leg;  foot  displaced 
backward  by  contraction  of  calf 
muscles;  lower  pointed  end  of  upper 
tibial  fragment  protruding  subcu- 
taneously  on  front  of  leg.  Fracture 
of  fibula  comminuted  and  typically 
higher  than  that  of  tibia.  Episcopal 
Hospital. 


378 


FRACTURES 


up  in  plaster  of  Paris  at  once,  in  eases  where  the  condition  of  tlie 
soft  parts  will  admit  of  this  procedure,  and  in  which  reduction  can 
be  surely  maintained  while  the  plaster  is  setting;  in  this  case  the 
dressing  must  extend  from  the  toes  to  above  the  knee,  and  it  is  very 
important  to  keep  the  foot  at  a  right  angle  with  the  leg.    The  gypsum 


Fig.  381. — Loni;  fiactiiro  bux,  fur  fracture  of  hones  of  leij;.  Xoto  (lr\-  dressing  over 
wound  of  compounil  fracture  of  tibia  and  foot  bandaged  to  fo(jt  piece.  Episcopal 
Hospital. 


case  must  be  renewed  at  the  end  of  a  week  or  ten  days,  as  subsidence 
of  the  primary  swelling  will  have  rendered  it  loose  and  hence  useless 
in  keeping  the  fragments  in  good  position.  In  cases  where  the  primary 
swelling  is  great,  with  bullae,  ecchymoses,  etc.,  it  is  better  to  postpone 
the  application  of  a  plaster  of  Paris  dressing  for  a  week  or  ten  days, 


Fig.  3S2. — Long  fracture  box  for  fracture  of  bones  of  leg,  sides  raised  and  fastened 
around  leg.     Episcopal  Hospital. 


keeping  the  leg  meantime  in  a  fracture  box  (Figs.  3S1  and  382), 
securely  packed  into  a  pillow  which  fills  up  all  irregularities  and  keeps 
the  leg  straight;  a  small  shot-bag  may  be  laid  over  the  projecting 
fragment.  While  in  the  fracture  box  great  care  must  be  exercised  to 
protect  the  heel  and  malleoli  from  pressure  by  "floating"  the  former 


FRACTURES  OF   THE  FIBULA 


379 


on  a  compress  placed  under  the  tendo  Aehillis.  and  hy  suitably  pad- 
ding,' the  malleoli;  and  the  heel  should  he  kept  down  against  the  foot- 
piece  of  the  fracture  hox,  to  i)revent  ccpiinus  deformity.  Rotatory  dis- 
placement of  either  the  upper  or  lower  frai,nncnt  inust  he  piarded 
against.  Another  very  good  dressing  is  the  posterior  wire  frame  of 
Cabot,  i^laced  under  tlie  lower  extremity  from  the  gluteal  crease  to  the 
ends  of  the  toes,  the  wire  ])eing  suitably  padded,  and  the  splint  covered 
with  cotton  cloth.  The  limb  is  then  laid  on  this  over  folded  sheets 
or  towels  so  applied  as  to  equalize  pressure  and  leave  the  heel  free; 
one  or  two  lateral  splints  are  then  applied,  and  fastened  to  the  frame 
and  each  other  b\-  adhesive  plaster  or  webbing  straps  with  buckles. 


Fig.  383.— Skiagrai)h  of  Pott's  fracture  of  left  leo 
Episcopal  Hospital. 


A<i:('  forty-two  years. 


Fractures  of  the  Fibula.— /^racf?/ re  of  the  shaft  of  this  bone  is  rare, 
except  when  accompanied  by  fracture  of  the  tibia,  to  which  it  usually 
is  secondary.  In  such  cases  the  treatment  described  above  for  fracture 
of  the  tibia  is  to  be  employed.  Isolated  fracture  of  the  upper  part 
of  the  shaft  of  the  fibula  often  results  in  delayed  union  or  non-union, 
as  it  is  very  difficult  to  secure  apposition  of  the  ends  of  fragments 
buried  in  such  a  mass  of  muscular  tissue.     Fracture  of  the  lower  fifth 


380 


FRACTURES 


of  the  fibula  is  a  very  frequent  injury,  resulting  from  indirect  violence, 
the  foot,  as  a  rule,  being  turned  violently  outward  (eversion  fracture); 
as  the  astragalus  forces  the  external  malleolus  outward,  the  tibio- 
fibular ligaments  act  as  a  fulcrum,  so  that  the  fibula  is  bent  in  against 
the  tibia  above  the  attachment  of  these  ligaments,  and  finally  breaks 
at  this  point,  two  or  three  inches  above  the  ankle-joint;  the  internal 
malleolus  often  is  avulsed  from  the  tibia,  at  the  same  time  (Fig.  383); 
and  to  this  combined  lesion  the  name  of  Potfs  Fracture  is  given,  it 
having  been  studied  carefully  and  graphically  described  by  Pott 
in  1771.     A  somewhat  similar  lesion  mav  result  from  inversion  of 


Fig.  384. — Skiagraph  of  fracture  of  lower  fifth  of  fibula,  internal  malleolus  and 
posterior  articular  surface  of  tibia,  with  posterior  dislocation  of  the  foot.  Episcopal 
Hospital. 

the  foot,  but  then  usually  the  fracture  of  the  fibula  detaches  merely 
the  external  malleolus,  and  the  tibial  fracture  enters  the  ankle-joint. 
Xo  accurate  description  can  be  given  of  the  lines  of  fracture  in  these 
various  injuries,  as  they  vary  greatly  in  different  cases.  Other  lesions, 
which  may  or  may  not  be  present,  are  rupture  of  the  tibio-fibular 
ligament,  rupture  of  the  internal  lateral  ligament  of  the  ankle  without 
fracture  of  the  internal  malleolus,  fracture  of  the  external  border  of 
the  articulating  surface  of  the  tibia,  separation  of  the  lower  tibial 
epiphysis,  or  posterior  dislocation  of  the  ankle-joint  (Fig.  384). 

Sjrmptoms. — Symptoms  of  Pott's  fracture  are  a  well-marked  and 
characteristic  deformity,  consisting  in  eversion  of  the  foot,  and  marked 


FRACTURES  OF  TIII'J  FIBULA 


381 


prominriK'o  of  the  internal  malleolus  or  of  the  lower  end  of  the  tibia 
when  the  malleolus  is  avulsecl;  almost  always  there  is  a  tendency 
for  the  foot  to  slide  backward,  causing  elongation  of  the  heel  and 
prominence  of  the  tibia  anteriorly.  As  a  rule,  lateral  mobility  is 
marked,  and  crepitus  easily .  detected.  But  since  fracture  in  this 
region  occasionally  exists  without  displacement,  being  subperiosteal 
or  imi)acte(l,  the  surgeon  always  should  treat  a  suspected  case  as  one 
of  fracture  until  this  can  be  dis])roved  by  skiagraphy  or  otherwise. 

Treatment. — Accurate  reduction  is  im- 
perative if  a  good  result  is  to  be  obtained: 
imperfect  reduction  in  an  antero-posterior 
direction  will  limit  (h^rsal  flexion  of  the 
ankle,  and  imperfect  correction  of  the 
eversion  will  render  the  patient  liable  to 
develop  static  flat-foot,  and  will  cause  last- 
ing disability  in  locomotion  (Fig.  385). 
Sometimes  general  anesthesia  is  necessary 
to  secure  reduction.  Grasping  the  heel 
in  one  hand,  and  the  leg  in  the  other,  the 
surgeon  brings  the  foot  forward  until  the 
astragalus  bears  its  normal  relation  to  the 
tibia,  and  then  supinates  the  foot,  so  as  to 
replace  the  internal  malleolus  and  over- 
come the  internal  bowing  of  the  fibula.  If 
there  is  little  reaction  in  the  soft  parts  a 
plaster  of  Paris  dressing,  from  toes  to  knee, 
may  be  applied  at  once,  to  be  renewed  in 
a  week  or  ten  days.  In  most  cases,  how- 
ever, it  is  safer  to  dress  the  leg  tempor- 
arily in  a  fracture  box,  with  a  pad  below  the  external  malleolus  and  one 
above  the  internal  malleolus  to  overcome  eversion,  and  with  careful 
support  to  the  heel,  keeping  this  well  down  against  the  footboard  so  as  to 


Fig.  38.5. — Deformity  follow- 
ing unreduced  Pott's  fracture  of 
left  foot,  two  months  after  in- 
jury.    Episcopal  Hospital. 


FiQ.  383. — Dupuytren's  splint  for  Pott's  fracture.     Note  pads  along  tibial  surface 
of  leg,  allowing  inversion  of  foot.     Episcopal  Hospital. 


prevent  the  development  of  a  pointed-toe  deformity;  or  the  leg  may 
be  dressed  in  Pott's  position  on  a  Dupuytren  splint  (1819)  (Fig.  386). 
Weight  should  not  be  borne  on  the  foot  for  at  least  eight  weeks.  In 
many  cases,  where  reduction  has  been  imperfect,  stiffness  and  edema 
may  persist  for  some  months,  and  may  require  massage,  passive 
motion,  baking,  etc.,  for  their  relief. 


382 


FRACTURES 
FRACTURES  OF  THE  FOOT. 


Fractures  of  the   Tarsus   usually  result  from  direct  \iolence   or 
falls   on   the   feet,   and   often   are   impacted.     Localized   tenderness 


Fiu.  3S7. — Impacted  fracture  of  neck  of  right  astragalus.     Episcopal  Hospital. 


Fig.  388. — Skiagraph  of  fracture  of  calcaneum,  comminuted  and  impacted. 
Episcopal  Hospital. 


FRACTURES  OF   TIIIC  FOOT 


383 


following]:  severe  injury  is  the  most  valuahle  symptom,  since  swelling; 
oF  the  soft  parts  may  ohseure  deformity,  and  since  mol)iiity  and 
crei)itus  frecjuently  are  ahsent.  ('orresjjondiiiif  injuries  often  exist 
in  both  feet,  and  two  or  more  l)ones  often  are  fractured  in  the 
same  foot.  The  a.stragaliift  most  frequently  is  broken  through  its 
neek  (Fig.  'AST;  see  also  p.  414).  Fractures  of  tlie  caJcancinn  are 
more    frequent,   and    often    may   l)e  diagnosed    clinically    from   the 


Fig.  .389. — Fracture  pf  second,  third,  fourth,  and  fifth  metatarsal  bones.     Heavy 
.stone  fell  on  foot.     Age  twenty-three  years.     Episcopal  Hospital. 

flattening  of  the  heel  and  prominence  of  the  calcaneum  below  the 
external  malleolus;  if  the  fracture  detaches  the  posterior  half  this 
may  be  considerably  displaced  upward  by  the  tendo  Achillis;  more 
often  there  is  a  general  crush  of  the  bone  (Fig.  388) .  These  fractures 
are  best  treated  by  immobilization  in  good  position  in  plaster  of  Paris 
for  three  or  four  weeks;  but  weight -bearing  should  not  be  allowed  for 
several  months.  Traumatic  flat-foot  should  be  corrected  by  moulding 
the  foot  over  the  surgeon's  knee  or  a  sand  pillow,  as  the  plaster  sets; 


384 


FRACTURES 


division  of  the  tendo  Achillis  may  be  necessary;  the  eversion  of  the 
heel  should  be  corrected  also.  If  impaction  of  the  calcaneum  with 
deformity  cannot  be  overcome  without  incision,  it  will  be  proper  to 
do  osteotomy  of  the  heel  portion  so  as  to  restore  the  normal  weight- 
bearing  surfaces.  This  has  been  done  by  Chutro  (1909)  as  a  secondary 
operation. 


Fig.  390. — Fracture  of  tuberosity  of  fifth  metatarsal  bone;  patient  had  been  treated 
for  "sprain  of  foot."     Age  twenty-three  years.     Episcopal  Hospital. 


Fractures  of  the  Metatarsus. — The  metatarsal  bones  usually  are 
fractured  by  direct  violence,  usually  two  or  three  at  once  (Figs.  389) . 
Deformity  is  slight,  but  disability  may  be  great.  Diagnosis  is  based 
on  persistent  localized  tenderness  usually  with  mobility,  and  some- 
times crepitus.  Fracture  of  the  base  of  the  fifth  metatarsal  bone  (Fig. 
390),  or  epiphyseal  separation  at  this  point,  which  is  a  less  frequent 
injury,  sometimes  occurs  from  direct  injury  in  stepping  on  the  outer 
side  of  the  foot. 

Fractures  of  the  Phalanges  are  rare,  even  from  direct  violence, 
and  then  usually  are  compound  and  require  amputation. 


CHAPTHR   XIII. 
INJURIES  OF  JOINTS. 

Sprains  and  Contusions. — A  sprain  is  an  injury  to  the  lijijamcntous 
striK'turrs  surroundin*;'  a  joint,  caused  by  a  wrench  or  a  twist;  there 
may  he  a  suhhixation  or  actual  dislocation  of  the  bones  composinj^ 
the  joint,  spontaneously  reduced.  Uoss  and  Stewart  (H)ll),  main- 
tain that  every  sprain  is  a  sprain-fracture,  the  lijijament  giving  way 
at  its  bony  attachment.^  Contusions  are  rarer  than  sprains,  and 
are  due  to  direct  injury,  the  blow  being  received  over  the  joint  or 
being  transferred  to  it  through  the  bones;  by  the  latter  mechanism 
may  be  ex])laincd  fracture  or  displacement  of  intra-articular  cartilages 
(p.  412).  The  joints  most  often  sprained  are  those  of  the  foot,  wrist, 
shoulder,  and  elbow. 

Symptoms. — The  symptoms  of  the  two  conditions  are  those  of 
inflammation  in  general,  with  perhaps  the  added  special  symptoms 
of  synovitis  (p.  4G3),  thecitis  (p.  279),  or  sprain-fracture  (p.  298). 
The  joint  assumes  that  position  in  which  tension  is  least,  the  ankle 
being  in  slight  plantar  flexion  and  adduction,  the  wrist  in  flexion, 
etc.  The  swelling,  heat,  redness,  etc.,  may  appear  in  a  few  moments, 
but  if  the  joint  is  well  supported  {e.  </.,  by  a  shoe),  and  its  use  is  per- 
sisted in,  they  may  not  manifest  themselves  until  after  support  is 
removed.  In  the  foot  the  subastragalar  joint  is  that  most  frequently 
sprained,  the  lesion  being  referred  to  popularly  as  "sprained  ankle"; 
the  normal  range  of  its  lateral  motion  is  suddenly  exceeded  either 
in  abduction  or  adduction,  with  laceration  or  complete  rupture  of 
the  internal  or  external  lateral  ligaments  at  the  ankle;  and  in  some 
cases  there  is  a  diastasis  of  the  tibio-fibular  joint.  There  commonly 
is  efTusion  around  both  malleoli  (Fig.  391).  Distinction  from  fracture 
usually  is  possible  after  careful  examination,  by  excluding  abnormal 
mobility  or  localized  tenderness  of  the  bones  around  the  affected 
joint,  the  symptoms  in  sprains  pointing  to  the  soft  structures  as  the 
seat  of  lesion. 

Prognosis. — The  prognosis  is  good,  though  in  some  rheumatic 
patients  slight  disability  may  persist  for  months;  and  in  a  few  cases, 
especially  sprains  of  the  shoulder,  periarthritis  may  ensue  (p.  4(3G). 

Treatment. — When  seen  early,  it  is  best  to  strap  the  ankle  with 
adhesive  plaster  (Fig.  392),  applying  a  firm  bandage  over  this.  In 
mild  sprains,  limited  use  of  the  joint  may  be  allowed  when  thus  sup- 
ported, but  in  severe  cases  the  foot  should  be  elevated,  and  kept  at 
rest  for  several  days.    This  strapping  should  be  renewed  every  third 

1  By  a  "strain"  usually  is  understood  a  sprain  of  slight  degree,  in  which  the 
tendinous  rather  than  the  ligamentous  structures  are  injured. 
25 


38G 


INJURIES  OF  JOINTS 


or  fourth  day,  and  may  well  be  continued  until  function  of  the 
joint  can  be  resumed.  In  cases  not  seen  until  marked  swellin*;  has 
developed,  it  is  safer  to  treat  the  joint  with  anodyne  or  evaporating 
lotions  until  tenderness  and  swelling  begin  to  al)ate.  Sprains  of  the 
joints  of  the  upper  extremity  may  be  dressed  with  ichthyol  or 
belladonna  and  mercury  ointment,  and  the  limb  carried  in  a  sling. 
Absolute  immobilization  (plaster  of  Paris,  etc.)  rarely  is  advisable, 
as  tending  to  promote  stiffness  by  interference  with  the  circulation 
of  blood  and  lymph.  In  later  stages  much  benefit  is  derived  from 
alternate  hot  and  cold  douches,  massage,  and  gentle  j)assive  motion. 


Fig.  391. — Sprained  right,  ankle  (recent 
accident).     Episcopal  Hospital. 


Fig.  392. — Adhesive  jihister  .strapping  for 
ankle.     Episcopal  Hospital. 


Wounds  of  Joints. — Open  wounds  of  joints  usually  are  very  serious 
lesions,  since  joints  are  very  susceptible  to  infection.  They  may  be 
incised,  lacerated,  punctured,  etc.  Gunshot  wounds  of  joints  have 
been  considered  in  Chapter  VII. 

Diagnosis. — The  diagnosis  usually  can  be  made  by  noting  the 
situation  and  depth  of  the  wound,  or  by  observing  the  escape  of 
synovial  fluid,  and  the  increase  in  its  flow  on  manipulation  or  pressure 
of  the  joint;  under  no  circumstances  should  a  joint  wound  be  probed 
with  finger  or  instrument  until  all  proper  aseptic  preparations  have 
been  made. 

Prognosis. — The  prognosis  depends  on  the  joint  injured,  on  the 
nature  of  the  injury,  on  the  constitutional  state  of  the  patient,  and 
on  the  treatment  employed.  Except  the  vertebral  joints,  the  knee 
is  the  most  dangerous  joint  in  the  body,  but  no  joint  wound  can  be 
regarded  as  trivial:  even  those  of  the  phalanges  may  require  ampu- 
tation, or  at  least  result  in  ankylosis.  Infection  is  the  great  danger, 
and    even    supposedly    aseptic    operations    occasionally    terminate 


DlSmCATIONS  387 

fatally  when  the  knee  is  involved  (p.  375).  If  proper  treatment  is 
not  undertaken  promptly,  pyarthrosis  may  result,  followed  by  septi- 
cemia and  death,  in  spite  of  all  the  resources  of  surgery. 

Treatment. — If  seen  before  these  (■omj)lications  have  arisen,  the 
wound  should  be  packed  with  sterile  gauze,  and  the  limb  surrounding 
it  prepared  as  for  an  aseptic  operation;  then  any  foreign  bodies 
remaining  in  the  wound  (cinders,  clothing,  glass,  needle,  etc.),  should 
be  extracted,  enlarging  the  wound  if  necessary,  and  evacuating 
blood  and  clots  from  the  interior  of  the  joint;  this  should  then  be 
gently  irrigated  (not  sponged)  with  warm  saline  solution,  and  sutured 
with  provision  for  drainage.  The  joint  is  then  immobilized  by  splint 
or  plaster  of  Paris,  elevated,  and  surrounded  by  ice  bags.  In  the  case 
of  large  joints  weight-extension  should  be  applied.  Constitutional 
treatment  (purge,  diuretic,  sedative)  should  not  be  neglected.  If  the 
joint  does  well,  as  shown  by  the  absence  of  pain  and  fever,  the  drain 
may  be  removed  on  the  second  day,  and  immobilization  continued  for 
one  or  two  weeks,  when  function  should  be  very  gradually  resumed. 
If  the  signs  of  infection  arise  (pain,  fever,  leukocytosis),  indicating 
the  development  of  septic  arthritis,  the  dressing  must  be  removed 
promptly,  and  better  drainage  instituted;  this  may  be  accomplished 
by  a  counter-opening,  or  by  numerous  openings,  with  saline  irrigation 
once  or  twice  daily,  or  in  desperate  cases  by  wide  incision  of  the 
joint  (in  the  knee  by  dividing  the  tendo  patellae  and  acutely  flexing 
the  knee — Dudley  Allen,  1906),  and  stuflSng  the  synovial  cavity  with 
gauze.  One  thorough  application  to  the  opened  joint  of  a  strong, 
hot  antiseptic  often  will  check  the  infection,  usually  with  ankylosis 
as  a  result;  but  the  use  of  weaker  solutions  by  irrigation  is  of  doubtful 
value.  But  if  septicemic  symptoms  continue  in  spite  of  this  heroic 
treatment,  the  surgeon  has  only  two  resources  left:  these  are  excision 
and  amputation.  In  the  upper  extremity  the  former  usually  is 
successful,  as  it  sometimes  is  in  the  ankle-joint;  but  for  the  knee-joint 
amputation  usually  is  required,  and,  of  course,  should  be  resorted 
to  in  the  case  of  other  joints,  where  excision  has  failed.  Nor  should 
these  radical  operations  be  postponed  too  long,  as  when  adopted 
late  in  the  disease  even  they  may  fail  to  save  the  patient's  life. 

Hemarthrosis. — Hemarthrosis  may  follow  subcutaneous  wounds 
of  joints,  especially  gunshot;  in  such  cases  it  presents  no  special 
interest,  the  symptoms  being  those  of  acute  synovitis  (p.  463). 
But  it  may  follow  slight  contusion  in  cases  of  hemophilia,  and  in 
such  patients  may  be  a  very  serious  malady.  Under  no  circumstances 
should  such  a  joint  be  opened  for  exploration  or  drainage.  It  should 
be  put  at  rest,  ice  should  be  applied,  and  the  hemophilia  treated 
as  already  advised  (p.  227). 

DISLOCATIONS. 

Dislocation  or  luxation  of  a  joint  is  a  condition  in  which  the  articular 
surfaces  of  the  bones  forming  the  joint  are  no  longer  in  contact. 


388  INJURIES  OF  JOINTS 

Dislocations,  however,  may  be  complete  or  incomplete  {subluxation), 
the  articular  surfaces  in  the  latter  form  retaining  a  partial  contact 
with  each  other.  It  is  usual  to  classify  dislocations  as  traumatic, 
congenital,  and  spontaneous  or  pathological:  traumatic  dislocations  are 
those  resulting  from  the  application  of  force;  congenital  dislocations 
are  those  present  at  birth;  and  spontaneous  or  pathological  dislocations 
are  those  due  to  malformation  of  the  joint  surfaces  from  disease, 
or  to  laxness  of  the  periarticular  structures.  Dislocations  may  be 
simple,  compound,  or  complicated,  these  terms  having  the  same  sig- 
nificance as  when  applied  to  fractures;  they  may  be  recent  or  old, 
terms  of  relative  meaning,  and  which  sufficiently  explain  themselves; 
and  they  may  be  primitive,  when  the  displaced  bone  remains  where 
originally  placed  by  the  injury,  or  consecutive,  when  it  assumes  another 
position  owing  to  manipulations  by  bystanders,  the  surgeon,  etc. 
The  direction  of  the  dislocation  is  described  as  it  regards  the  distal 
bone  or  bones  forming  the  joint:  thus  posterior  dislocation  of  the 
elbow  means  that  the  forearm  (not  the  humerus)  is  displaced  back- 
ward ;  but  there  are  a  few  exceptions  to  this  rule,  which  will  be  noted 
later. 

In  the  present  chapter  only  traumatic  dislfK-ations  are  considered, 
pathological  dislocations  being  discussed  with  diseases  of  the  joints, 
in  Chapter  XV,  and  congenital  dislocations  in  connection  with 
orthopedic  surgery,  in  Chapter  XVI. 

Causes. — As  in  the  case  of  fractures,  the  mule  sex  and  active  adult 
life  act  as  predisposing  causes  of  luxation.  Certain  joints  are  dis- 
located much  more  commonly  than  others:  the  shoulder  contributes 
about  50  per  cent,  of  all  dislocations,  while  the  elbow,  the  clavicle, 
and  the  phalanges  contribute  only  about  5  to  10  per  cent,  each;  the 
hip,  ankle,  and  lower  jaw  contribute  from  3  to  5  per  cent,  each;  while 
the  wrist,  knee,  etc.,  are  very  rarely  dislocated. 

Dislocations  are  caused  much  more  often  by  indirect  than  direct 
violence.  Usually  the  motion  of  the  joint  is  forced  beyond  its  normal 
limit,  the  distal  bone  impinging  against  a  fulcrum  formed  by  a  neigh- 
Ijoring  bone;  the  capsular  ligament  is  thus  ruptured  at  its  weakest 
point,  and  the  head  of  the  dislocated  bone  is  forced  through  this 
opening  either  by  continuation  of  the  original  force,  or  rarely  by 
secondary  muscular  contraction.  It  thus  happens  that  in  each 
joint  there  is  a  more  or  less  typical  primitive  dislocation,  because  the 
head  of  the  bone  habitually  emerges  at  the  weakest  part  of  the  capsule 
If  direct  violence  is  the  cause,  the  capsule  and  accessory  band-like 
ligaments  are  widely  ruptured,  and  the  head  of  the  bone  may  pass 
almost  in  any  direction.  In  luxations  caused  by  leverage  (the  usual 
mechanism),  the  tear  in  the  capsule  always  is  sufficient  to  allow 
passage  of  the  head;  but  it  is  the  capsule  which  ofFers  the  main  obstacle 
to  reduction  since  by  secondary  displacement  of  the  luxated  bone, 
and  by  its  rotation  on  its  long  axis,  the  tear  in  the  capsule  becomes 
converted  into  a  slit  with  tense  margins.  But  though  this  slit-like 
opening  in  the  capsule   is  the  main  obstacle  to  reduction  further 


DismcArioNS  389 

(.liffit'ulty  is  ailurcleci  by  muscular  contraction  and  resiliency,  wliicii 
keep  the  hone  in  its  ahnormal  position. 

Symptoms."  Tlicrc  are  three  cardinal  syn)i)t()nis  of  dislocation. 
(1 )  Ahcration  in  contour  of  the  affected  joint,  the  head  of  the  hixated 
bone  l)ein<i  absent  from  its  socket  and  i)alpabK'  elsewhere.  (2)  Change 
in  length  of  the  affected  extremity^either  shortening  or  lengthening. 
(8)  Innnobility  or  loss  of  normal  mobility.  In  many  dislocations 
there  also  is  exident  (4)  Change  in  the  axis  of  the  dislocated  bone. 
The  only  pathognomonic  sign,  however,  is  the  first,  absence  of  the 
head  of  the  dislocated  bone  from  its  socket  and  its  presence  elsewhere; 
and  even  here  confusion  may  arise,  if,  as  in  cases  of  fracture  of  the 
surgical  neck  of  the  scapula  (p.  380),  the  socket  as  well  as  the  head 
of  the  l)one  is  displaced.  In  general,  however,  a  dislocation  may 
be  distinguished  from  a  fracture  near  a  joint,  by  the  facts  that  in  a 
fracture  there  is  abnormal  mobility  and  bony  crepitus;  and  that  when 
deformity  is  reduced  it  frequently  recurs;  whereas  in  dislocation  the 
normal  mobility  is  decreased  or  entirely  lost,  there  is  no  true  crep- 
itus, and  deformity  does  not  recur  wdien  the  dislocation  is  reduced. 
But  in  dislocation  caused  by  direct  violence  the  periarticular  struc- 
tures are  so  widely  disrupted  that  abnormal  mobility  may  exist,  and 
deformity  may  persistently  recur;  and  in  some  cases  there  may  be 
an  indistinct  moist  crepitus  due  to  contrition  of  the  luxated  bone 
with  the  side  of  the  socket;  moreover,  dislocation  and  fracture  may 
be  present  in  the  same  joint,  symptoms  of  both  conditions  being 
evident.  The  skiagraph  offers  a  controlling  test  by  which  almost 
always  it  is  possible  to  ascertain  the  true  lesion. 

Damage  to  periarticular  structures — nerves,  bloodvessels,  tendons — 
may  occur  in  dislocation,  as  in  fracture,  and  always  should  be  looked  for 
before  attempts  at  reduction  are  made.  Other  evidences  of  local  injury, 
such  as  pain,  swelling,ecchymosis,  etc.,  do  not  require  special  description. 

Changes  in  the  Joint  Surfaces  occur  within  a  comparatively  short 
time,  if  the  dislocation  is  not  reduced.  There  always  is  a  certain 
amount  of  blood  extravasated,  filling  the  capsule;  and  as  this  organizes 
the  socket  becomes  shallower,  the  capsular  tear  cicatrizes  and  con- 
tracts, the  surrounding  ligaments,  tendons,  bloodvessels,  and  nerves 
become  adherent  in  the  newdy  formed  scar-tissue;  and  the  longer  the 
dislocation  remains  unreduced,  the  more  difficult  is  it  to  secure 
reposition.  In  the  course  of  time  the  luxated  bone  forms  for  itself 
a  new  socket,  which  will  furnish  a  certain  degree  of  solidity  and 
permits  a  moderate  amount  of  motion. 

Prognosis. — Prognosis  is  good  in  the  majority  of  cases  as  to  both 
life  and  function.  Dislocations  very  rarely  are  fatal  injuries  unless 
compound  or  complicated.  Beyond  a  weakness  or  stiffness  lasting 
some  weeks  or  possibly  months,  most  patients  whose  dislocations 
have  been  promptly  and  skilfully  reduced  suffer  no  further  incon- 
venience; but  where  reduction  is  delayed,  or  where  unusual  force  has 
been  employed  in  securing  reduction,  a  certain  amount  of  disability 
may  persist  for  years  or  throughout  life. 


390  INJURIES  OF  JOINTS 

Treatment. — In  recent  dislocations  efforts  at  reduction  should  be 
made  at  once,  unless  the  patient  is  profoundly  shocked.  In  many 
cases  general  anesthesia  is  desirable  to  relieve  the  pain  and  abolish 
muscular  contraction,  which  is  aroused  anew  at  every  attempt  to 
manipulate  the  limb.  Dislocations  are  reduced  by  two  methods, 
which  may  be  termed  the  direct  and  the  indirect  (G.  G.  Davis,  1910) : 
in  the  former  the  limb  is  first  placed  in  the  attitude  in  which  it  was 
when  the  dislocated  bone  burst  through  its  capsule,  and  the  head 
of  the  bone  is  then  pushed  or  pulled  directly  back  tlirough  the  rent 
in  the  capsule  into  its  socket;  in  the  indirect  method  the  limb  is 
manipulated  in  such  a  way  as  to  bring  into  use  the  capsule  itself  and 
surrounding  ligaments  as  a  series  of  sliding  fulcra,  by  means  of  which 
the  dislocated  bone  is  levered  into  its  socket.  If  an  anesthetic  is 
administered,  completely  abolishing  muscular  contraction,  no  obstacle 
to  reduction  remains  except  the  joint  capsule,  and  it  depends  on  the 
skill,  patience,  and  dexterity  of  the  surgeon  to  insinuate  the  head 
of  the  dislocated  bone  tlirough  the  capsular  opening  into  the  socket; 
for  this  to  be  accomplished,  no  force  is  required  beyond  what  may  be 
exerted  by  the  surgeon  s  hands.  The  capsule  is  an  inelastic  structure, 
and  the  tear  tlu-ough  which  the  dislocated  bone  emerges  always  is 
as  large  as  and  sometimes  larger  than  the  head  of  the  bone  itself. 
If  no  anesthetic  is  given,  it  may  be  necessary  to  supplement  the 
surgeon's  own  power  by  weight-extension,  gravity,  etc.,  especially  if 
the  patient  has  a  highly  developed  muscular  system;  in  other  cases  it 
will  be  easy  to  reduce  the  luxation  by  taking  the  muscles  by  surprise, 
as  it  were,  and  replacing  the  bone  while  the  patient  thinks  a  mere 
preliminary  examination  is  being  conducted. 

All  efforts  at  reduction  by  conservative  means  having  failed,  the 
surgeon  may  resort  to  artlirotomy,  by  which  he  will  be  enabled  to 
enlarge  the  rent  in  the  capsule,  and  to  displace  tendons,  ligaments, 
etc.,  caught  around  the  head  of  the  bone,  this  latter  condition  being 
almost  the  sole  factor  which  renders  a  recent  dislocation  really  irre- 
ducible. Usually  operation  is  not  undertaken  until  several  days 
after  the  injury,  various  surgeons  having  meantime  maltreated  the 
limb  by  applying  excessive  force  in  attempts  at  reduction;  this  renders 
the  operation  more  difficult  and  less  likely  to  be  successful  than  if 
done  before  such  unskilful  attempts  have  been  made. 

Reduction  having  been  secured,  the  joint  should  be  kept  at  rest, 
in  such  a  position  as  to  prevent  re-dislocation,  for  a  period  of  ten  days 
or  two  weeks;  and  for  several  weeks  longer  all  violent  motions,  or 
even  gentle  motions  of  wide  range,  should  be  prohibited.  Massage 
often  is  beneficial. 

Compound  Dislocations  are  to  be  treated  according  to  the  principles 
inculcated  when  speaking  of  wounds  of  joints.  Owing  to  the  great 
force  necessary  for  their  production,  and  the  wide  laceration  of  the 
soft  parts,  reduction  usually  is  easy.  They  are  most  frequent  at  the 
elbow  and  ankle. 


SPECIAL  DISLOCATIONS  301 

Complicated  Dislocations.  Fniclurcs  (•()iiii)li(:itiii^- dislocations  are 
discussed  at  \).  '.W'l.  Hiipliirf  of  Ihc  iikiIii  vessels  at  a  dislocated  joint 
is  to  he  treated  as  a  wound  of  the  \<'ssels  under  other  circumstances. 
Lesions  of  iwrirs  acconii)anyint;-  dislocation  should  he  treated  con- 
servatively until  no  further  improvement  can  be  expected;  unless, 
of  course,  it  is  evident  that  complete  rupture  of  a  nerve  trunk  has 
occurred,  when  primary  suture  should  be  done. 

Old  Dislocations. — Some  dislocations  become  "old"  much  sooner 
than  others,  and  it  is  not  always  advisable  to  attempt  reduction. 
Sir  Astley  Cooper  (1822)  set  three  months  as  the  limit  for  the  shoulder, 
and  eight  weeks  for  the  hip,  not  because  reduction  could  not  sometimes 
be  obtained  after  the  lapse  of  a  longer  time,  l)ut  because  it  was  secured 
at  the  ex})ense  of  such  damage  to  the  soft  parts  that  the  remedy  was 
worse  than  the  disease.  The  first  question,  therefore,  w-hich  arises 
in  a  ease  of  old  dislocation,  is  whether  or  not  reduction  shall  be  at- 
tempted. And  it  may  be  answered  affirmatively  in  almost  every 
case,  since  even  though  the  attempt  prove  a  failure  a  skilful  surgeon 
by  judicious  and  gentle  manipulation  of  a  dislocated  joint  almost 
invariably  wall  be  able  to  improve  the  function  of  the  part.  But 
as  to  whether  attempts  at  reduction  will  be  successful,  it  is  much 
more  difficult  to  formulate  an  answer,  much  depending  on  the  duration 
of  the  condition,  the  age  of  the  patient,  and  the  joint  involved.  At 
the  present  day  mere  duration  of  the  condition  is  very  little  con- 
sidered, since  should  reduction  fail  by  manipulation,  it  may  succeed 
by  arthrotomy;  and  as  a  last  resort  the  surgeon  may  have  recourse 
to  excision  of  the  joint  or  of  the  head  of  the  dislocated  bone,  an 
operation  which  generally  will  improve  function,  though  not  restoring 
it  to  normal.  But  the  age  of  the  patient  is  an  important  consideration; 
in  the  very  old,  wdiile  manipulation  might  succeed  in  securing  reduc- 
tion more  easily  than  in  those  of  active  middle  life,  yet  the  risk  of 
producing  fracture  w^ould  be  so  great,  and  the  advantages  to  be  gained 
so  temporary,  that  as  a  rule  it  is  better  to  leave  the  joint  alone 
unless  the  condition  is  very  disabling.  The  hip-joint  is  that  in  wdiich 
dislocation  becomes  irreducible  most  rapidly;  the  knee  probably  is 
second,  the  elbow  third,  and  the  shoulder  fourth.  But  in  the  hip 
and  the  shoulder,  especially  the  latter,  if  massage  and  passive  motion 
are  persisted  in  long  enough,  a  fair  range  of  motion  may  be  secured 
wdthout  reduction.  In  the  elbow  artlirotomy  usually  will  be  successful 
in  securing  reduction  and  a  useful  limb;  while  in  the  knee  excision 
may  be  required. 

Recurrent  Dislocations  are  commonest  at  the  shoulder,  and  may 
require  pleating  of  the  capsule  by  suture  as  practised  bv  T.  T.  Thomas 
(1909). 

SPECIAL  DISLOCATIONS. 

Mandible. — Usually  this  is  produced  through  muscular  action  in 
yawning,  though  it  may  follow  a  downw^ard  blow  on  the  chin.  The 
luxation  may  be  unilateral  or  bilateral,  and  the  displacement  nearly 


392 


INJURIES  OF  JOINTS 


invariably  occurs  forward:  the  condyle  ruptures  the  weak  anterior 
portion  of  the  capsular  ligament,  rides  forward  on  the  eminentia 
articularis  beyond  its  normal  limit,  and  is  held  there  by  spasmodic 
contraction  of  the  external  pterygoid  muscle,  assisted  by  the  tem- 
poral and  masseter.  The  mouth  remains  open,  and  if  only  one  side 
of  the  jaw  is  dislocated,  the  chin  is  displaced  to  the  other  side. 

Treatment. — Reduction  is  secured  by  forcibly  opening  the  mouth 
further,  at  the  same  time  depressing  the  body  of  the  bone  by  placing 
the  thumbs  (carefully  guarded  by  adhesive  plaster,  gauze,  etc.) 
over  the  back  molar  teeth,  and  finally  raising  the  chin  by  the  dis- 
engaged fingers.  Recurrence,  not  very  rare,  should  be  prevented  by 
application  of  a  bandage,  such  as  Barton's,  for  about  ten  days. 

Subluxation  of  ilie  jaw  is  a  term  employed  by  Sir  Astley  Cooper 
(1S22)  to  describe  a  frequently  repeated,  usually  self-reduced,  uni- 
lateral displacement  of  the  mandibular  condyle,  due  to  looseness 
of  the  intra-articular  cartilage.  In  mild  cases  it  constitutes  the 
condition  known  as  "clacking  jaw";  aside  from  the  noise  of  the  car- 
tilage slipping  around,  which  is  audible  to  the  patient  and  occasionally 
to  those  close  to  him,  little  inconvenience  is  experienced.  Treatment, 
when  any  is  required,  consists  in  administration  of  tonics,  use  of 
counter-irritants,  injection  of  formalin  or  alcohol,  and,  as  a  last 
resort,  excision  of  the  cartilage. 

Central  dislocation  of  the  jaw  is  a  very  rare  lesion,  usually  fatal, 
in  which  the  condyle  is  driven  through  the  base  of  the  skull. 

Vertebrae. — See  Chapter  XVII. 

Clavicle. — This  bone  may  be  dislocated  at  either  end,  dislocation 
at  the  acromio-clavicular  joint  forming  an  exception  to  the  rule  for 
nomenclature  of  luxations  formulated  at  p.  388. 


Fig.  393.  —  Mechanism  of  dislocation  of 
right  sterno-elavicular  joint.    See  text. 


Fig.  394. — Mechanism  of  dislocation  of 
right  acromio-cla\'icular  joint.  See  text. 


Dislocation  of  the  Sterno-elavicular  Joint. — The  clavicle  usually 
is  displaced  upward  and  forward.  The  injury  is  produced  by  falls 
or  blows  causing  sudden  depression  of  the  shoulder,  the  clavicle 
coming  into  contact  with  the  first  rib  close  to  the  sternum;  as  the 


DISLOCATION  OF   THE  CLAVICLE 


393 


costo-c'lavit'ular  lij^aiueiit  prevents  the  ehiviele  from  ^nvinj^  at  the 
point  of  attaeliment,  the  inner  extremity  is  pried  out  of  its  socket 
over  the  first  rih  as  a  fuU-runi  (Fi^. 
',\\y.\).  The  intra-articuhir  cartihi^e 
usually  is  disijlaeed  with  the  clavi- 
cle. Si/iiii)t(»)i.s  are  self-evident  (Fi^- 
39o),  and  reduction  is  easy  to  secure 
by  raisiuij;  the  outer  end  of  the  clavi- 
cle and  drawing  the  shoulder  hack- 
ward;  but  it  is  difficult  to  prevent 
recurrence.  The  arm  may  be  carried 
in  a  sling,  and  a  firm  spica  of  the 
shoulder  a])plied  (Fig.  S())  with  a 
pad  over  the  iinierend  of  the  clavi- 
cle. Some  deformity  almost  always 
persists,  but  function  is  good.  In 
some  cases  the  joint  may  be  opened 
and  the  l)ones  sutured  in  place. 
Backward  dislocation  at  the  sternal 
end  is  rare,  and  may  be  accompanied 
l)y  dyspnea,  dysphagia,  etc.  In  the 
only  patient  I  have  .seen,  under  the 
care  of  Dr.   F.   T.   Stewart  in  the 

Pennsylvania  Hospital,  the  only  pressure  eflfects  were  due  to  com- 
pression of  the  subclavian  vein,  and  were  promptly  relieved  by 
drawing  the  shoulder  backward.    A  posterior  figure-of-eight  bandage 


Fi(i.  39."). — Kecunent  dislocation  of 
sternal  end  of  right  clavicle.  Ortho- 
IJffidic  Hospital. 


Fig.  396. — Dislocated  acromial  end  of  right  clavicle.     Injury  eighteen  months  ago. 

Episcopal  Hospital. 


(Fig.  89)  makes  a  good  dressing.  Downward  dislocation  at  this  joint 
may  occur  when  fracture  of  the  first  rib  coexists;  it  is  a  serious 
injury,  the  result  of  great  direct  violence. 


394  INJURIES  OF  JOINTS 

Dislocation  of  the  Acromio-clavicular  Joint  usually  results  from 
depression  and  inward  rotation  of  the  scapula,  from  falls  or  blows 
on  the  point  of  the  shoulder.  This  carries  the  base  of  the  coracoid 
up  against  the  clavicle,  and  as  the  clavicle  is  fastened  to  this  by  the 
strong  coraco-clavicular  ligaments  the  only  motion  possible  is  an 
upward  displacement  of  the  acromial  end  of  the  clavicle,  the  coracoid 
acting  as  a  fulcrum  (Fig.  394).  The  deformity  is  self-evident  (Fig.  396), 
and  like  that  at  the  inner  end  is  easy  to  overcome  but  difficult  to 
keep  reduced.  However,  by  fixing  the  upper  extremity  in  the  Velpeau 
position,  with  the  dressing  advised  for  fracture  of  the  clavicle,  the 
turns  of  the  bandage  over  the  shoulder  and  under  the  flexed  elbow 
(Fig.  302)  will  keep  the  bones  in  place  as  long  as  the  bandages  remain 
firm.  This  dressing  should  be  continued  two  weeks  or  more.  As  in 
luxation  of  the  sternal  end,  suture  may  be  adopted  for  persistent 
deformity  if  it  entails  disability,  which  is  rare.  Doicmvard  and  back- 
ivard  dislocations  occur,  but  are  very  unusual. 

Scapula. — The  only  dislocation  of  this  bone  recognized  by  system- 
atic writers  consists  in  displacement  of  its  lower  vertebral  border 
from  beneath  the  fibres  of  the  latissimus  dorsi,  usually  from  indirect 
violence  or  muscular  strain.  If  firm  bandaging  is  not  sufficient,  the 
muscle  may  be  re-attached  by  suture.  The  deformity  seen  in  some 
cases  of  phthisis  (winged  scapula),  and  after  paralysis  of  the  serratus 
magnus  muscle,  closely  simulates  this  "dislocation"  of  the  scapula. 

Shoulder. — Dislocations  of  the  head  of  the  humerus  may  occur 
anterior  or  posterior  to  the  glenoid  cavity,  the  posterior  variety  being 
exceedingly  rare.  There  are  many  reasons  for  this:  the  shoulder 
usually  is  dislocated  by  injuries  which  produce  extreme  abduction 
of  the  arm,  and  as  the  force  generally  acts  from  the  front,  the  arm 
is  carried  backward  as  it  is  abducted.  As  the  glenoid  process  looks 
more  forward  than  outward,  such  a  motion  tlirows  most  strain  on 
the  anterior  part  of  the  capsule  of  the  shoulder-joint;  and  if  while 
the  arm  is  abducted  slightly  posteriori}^  an  inward  thrust  or  a  pull 
by  the  axillary  muscles  is  added,  this  portion  of  the  capsule  will  be 
ruptured;  or  if  abduction  continues  until  the  humerus  strikes  against 
the  acromion,  after  all  possible  leeway  has  been  gained  by  rotation 
of  the  scapula,  then  the  head  of  the  humerus  will  be  pried  out  of 
the  capsule  over  the  acromion  as  a  fulcrum.  The  capsule  is  torn 
loose  from  the  glenoid,  from  the  base  of  the  coracoid  above  to  the 
attachment  of  the  triceps  below;  and  through  this  rent,  which  may 
be  increased  by  rotation  of  the  humerus,  the  humeral  head  emerges 
in  the  axilla,  in  front  of  the  triceps.  If  the  arm  remains  in  the  position 
of  extreme  abduction,  which  is  extremely  rare,  the  condition  is  de- 
scribed as  luxatio  erecta;  usually,  by  the  force  of  gravity  or  the  assist- 
ance of  bystanders,  the  patient's  arm  is  brought  down  to  his  side, 
and  the  head  of  the  bone  passes  beneath  the  coracoid  (sub-coracoid 
dislocation)  where  it  usually  remains,  or  may  be  displaced  further 
inward,  into  a  subclavicular  position.  All  these  (axillary,  subcoracoid, 
subclavicular)  are  varieties  of  anterior  dislocations.     Posterior  dis- 


DISLOCATION  OF   THE  SHOULDER 


395 


locations,  unless  congenital,  usuall\  result  only  from  extreme  direct 
violence,  tearin*,'  loose  li<,'aments  and  tendons  on  all  sides;  or  some- 
times by  inward  rotation  and  adduction,  with  a  backward  thrust,  the 
lesser  tuberosity  impinjiiuK  on  the  coracoid  pro(-ess.  Sometimes 
they  are  secondary  disi)lacements,  the  primiti\e  dislocation  having 
been  anterior.  The  head  of  the  bone  may  be  displaced  only  slightly 
backward  {subacromial),  or  so  far  as  to  merit  the  term  subspinous. 

In  anterior  dislocations  the  subscapularis  muscle,  stretched  over 
the  capsule  at  the  point  of  rupture,  may  itself  be  perforated  by  the 
head  of  the  humerus,  though  usually  this  emerges  below  the  sub- 
scapularis. The  circumflex  or  musculo-spiral  nerve  may  be  stretched 
or  lacerated,  though  recent  observations  seem  to  show  that  the 
lesions  if  permanent  more  often  are  in  the  spinal  roots  forming  the 
outer  cord  of  the  brachial  plexus  (p.  28^).  In  most  cases  there  is 
tingling  and  numbness  in  the  fingers,  and  some  distention  of  the 
veins,  from  pressure  on  the  axillary  vessels. 


Fig.  397.— Recent  subcoracoid  luxation  of  left  humerus,  patient  aged  seventy  years. 
Reduced  without  anesthetic  by  Kocher's  method.     Episcopal  Hospital. 

Symptoms.— The  appearance  of  patients  with  dislocation  of  the 
shoulder  is  characteristic  (Fig.  397) :  the  arm  hangs  a  little  away  from 
the  side,  there  is  a  hollow  under  the  acromion,  and  the  head  of  the 
bone  may  be  seen  beneath  the  coracoid.  As  the  head  of  the  humerus 
has  been  displaced  from  its  pedestal,  and  has  been  drawn  against  the 
side  of  the  thorax,  and  as  the  thoracic  cage  is  convex,  it  is  impossible 
to  bring  the  elbow  against  the  side  of  the  chest  at  the  same  time  that 
the  hand  is  placed  on  the  uninjured  shoulder  (Dugas's  sign,  1856). 
In  recent  cases,  and  in  not  very  obese  patients,  the  diagnosis  is 
easy;  but  when  swelling  has  occurred,  and  after  much  manipulation 
bv 'others,  it  mav  be  quite  difficult;  and  it  is  in  such  circumstances 
that  Dugas's  sign  and  the  .r-ray  (Fig.  398)  become  valuable  aids. 

In  posterior  dislocation  the  head  of  the  bone  is  palpable  beneath 


396 


INJURIES  OF  JOINTS 


the  infraspinous  muscles,  the  glenoid  cavity  is  empty,  the  coracoid 
process  is  unusually  prominent,  and  the  other  usual  symptoms  of 
dislocation  are  present. 


Fig.  398. — Skiagrapli  of  suli-roracoid  dislocation  of  humerus.     (Coracoid  and 
glenoid  processes  emphasized.)      Episcopal  Hospital. 


Treatment. — The  indirect  metJwd  of  reduction,  or  that  by  manipu- 
lation, is  preferable.  This  was  proposed  in  1858  by  H,  H.  Smith, 
Professor  of  Surgery  in  the  University  of  Pennsylvania,  and  later 
(1863)  systematized  by  him;  he  thought  muscular  contraction, 
especially  that  of  the  supraspinatus,  as  taught  by  Sir  Astley  Cooper, 
was  the  main  obstacle  to  reduction.  Kocher,  later  Professor  of 
Surgery  in  Bern,  in  1870  adopted  a  similar  method,  founded  on  that 
of  Schinzinger  (1862) ;  he  recognized  the  capsule  as  the  chief  obstacle 
to  and  best  aid  in  securing  reduction. 

H.  H.  Smith's  Method  of  Reduction. — The  patient  being  on  his 
back,  (1)  elevate  the  arm  in  the  sagittal  plane  until  it  is  nearly  vertical 
(step  two,  of  Kocher's  method) ;  this  relaxes  the  supraspinatus  muscle, 
as  well  as  the  coraco-brachialis  and  short  head  of  the  biceps,  per- 
mitting step  tw^o  to  be  more  efTectually  executed.  (2)  Keeping  the 
arm  vertical,  and  using  the  bent  forearm  as  a  lever,  rotate  the  humerus 
outward;  by  doing  this  the  untorn  posterior  portion  of  the  capsule 
is  wound  around  the  head  and  upper  part  of  the  neck  of  the  humerus 
(Farabeuf,  1885),  and  acting  as  a  sliding  fulcrum  draws  the  head 


DISLOCATION  OF  THE  SHOULDER 


397 


of  the  bone  Jiway  from  the  chest,  until  the  suhscapularis  hcconies 
tense  and  resists  further  rotation.  (;3)  Then  slowly  atiduct  the  arm 
across  the  chest,  still  maintaining  outward  rotation  of  the  humerus; 
when  the  elhow  touches  the  chest,  th(>  hand  is  brought  down  to  the 
opposite  shoulder,  and  the  hone  usually  will  he  rci)laced. 


Fig.  399. 


-Kocher's  method  of  reducing  dislocation  of  .shoulder,  first  step:  outward 
rotation.    Episcopal  Hospital. 


T.  Kuchcr's  Method  of  Reduction. — (1)  Bring  the  elbow  against  the 
chest,  and  rotate  the  humerus  outward  as  far  as  it  will  go,  using  the 
bent  forearm  as  a  lever  (Fig.  399) ;  do  not  push  this  outward  rotation 
too  far,  and  do  it  with  a  very  gradual  and  gentle  but  persistent  motion ; 
force  is  very  liable  to  fracture  the  humerus;  Kocher  himself  broke 
it  three  times  in  reducing  twenty-eight  luxations.  During  this  out- 
ward rotation  of  the  humerus  the  same  phenomena  occur  as  during 


Fig.  400. — Reduction  of  dislocation  uf  shoulder  by  Kocher's  method;  second  step: 
elevation  of  arm  in  sagittal  plane.     Episcopal  Hospital. 


step  two  of  Smith's  method,  but  the  lesser  tuberosity  may  catch  under 
the  tense  coraco-l)rachialis,  and  this  is  one  cause  of  the  frequency 
of  fracture  of  the  humerus  (G.  G.  Davis,  1910).  (2)  Raise  the  elbow 
in  the  sagittal  plane,  or  in  slight  adduction,  until  the  arm  is  as  nearly 
vertical  as  possible  (Fig.  400) ;  this  relaxes  the  anterior  border  of  the 


398 


INJURIES  OF  JOINTS 


rent  in  the  capsule  (coraco-humeral  ligament),  and  the  coraco- 
brachial is  and  short  head  of  the  biceps,  which  hinder  the  ascent  of 
the  head  on  to  the  glenoid  process.  (3)  Rotate  the  arm  inward, 
using  the  bent  forearm  as  a  lever,  until  the  hand  touches  the  sound 
shoulder,  then  quickly  bring  the  elbow  to  the  side  of  the  chest  (Fig. 
401).  This  last  step  slides  the  head  of  the  bone  back  through  the 
rent  in  the  capsule,  whose  posterior  untorn  part  is  now  on  the  inner 
instead  of  the  outer  side  of  the  humerus,  and  again  acts  as  a  fulcrum 
to  lever  the  head  upward;  but  reduction  often  is  accomplished  at  the 
conclusion  of  the  second  step. 


Fig.  401. — Reduction  of  dislocation  of  shoulder  by  Kocher's  method;  third  step: 
hand  brought  to  shoulder  and  elbow  to  chest.     Episcopal  Hospital. 


Of  these  two  methods,  Smith's  undoubtedly  is  the  better,  though 
neither  of  them  rests  on  the  anatomo-pathological  basis  which  was 
erected  for  them  by  their  authors;  Smith  thought  the  muscles  the 
all  important  factor,  while  Kocher  thought  success  depended  on  the 
gleno-humeral  ligament,  which  was  shown  by  Farabeuf  to  be  of  no 
consequence.  The  great  advantage  of  these  methods  of  manipulation 
is  that  an  anesthetic  usually  is  not  required  in  recent  cases,  and  that 
they  can  be  applied  by  the  surgeon  without  other  assistance  than  the 
inertia  of  the  patient's  body.  They  depend  for  their  efficiency, 
however,  on  the  untorn  state  of  the  posterior  part  of  the  capsule;  if 
this  portion  also  is  torn,  the  head  of  the  humerus  will  not  be  pulled 
away  from  the  chest  during  outward  rotation,  but  will  rotate  in  situ. 
Under  such  circumstances  the  rent  in  the  capsule  will  be  so  large 
that  no  difficulty  should  be  experienced  in  replacing  the  head  of  the 
bone  by  direct  pressure,  after  it  has  been  drawn  away  from  the  chest 
by  extension  and  counter-extension. 

The  methods  of  direct  reposition  are  many;  all  of  them  depend 
first  on  bringing  the  head  of  the  bone  opposite  the  tear  in  the  capsule, 
and  consequently  aivay  from  the  chest  umll  and  out  to  the  neighborhood 
of  the  glenoid  process;  and  then  on  pushing  or  pulling  it  into  its  socket. 
The  head  can  be  brought  away  from  the  side  of  the  thorax  only  by 
eliminating  or  overcoming  the  muscular  contraction  which  holds 
it  there,  either  by  continuous  traction  or  a  general  anesthetic. 


DISLOCATION  OF   TlIM  SIIOULDEIi  :]{)9 

1.  Sir  A.silcy  Cooper's  Method  (1822):  With  tlic  patient  supine, 
plaee  the  heel  of  the  luihooted  foot  in  the  patient's  axilla,  against 
the  chest,  and  make  traction  downward  and  slightly  outward  on  the 
upper  extreuiitx';  the  traction  ])ulls  the  head  free  from  the  eoraeoid, 
and  l)v  slight  Ie\erag{>  o\(T  the  foot,  the  head  is  pushed  directly 
into  its  socket.  A  little  rotation  in  and  out  may  assist.  This  is  a 
very  efficient  method,  really  combining  all  others  (extension  and 
counter-extension,  leverage,  and  mauii)ulation),  but  it  is  very  painful 
and  usually  re(iuires  anesthesia;  and  the  inexpert  or  brutal  may 
cause  serious  injury  to  the  axillary  tissues. 

2.  Stimsons  Method  (1900:  The  patient  is  laid  on  a  canvas  sling, 
with  the  dislocated  extremity  passed  through  a  hole  in  the  canvas 
and  hanging  free  of  the  floor;  a  weight  of  about  ten  pounds  is  attached 
to  the  wrist  or  elbow.  The  liml)  is  kei)t  thus  in  abduction,  and  in 
a  few  minutes  (never  more  than  six,  Stimson)  reduction  of  the  dis- 
location takes  place  quietly  and  without  pain.  No  anesthetic  is 
required,  as  the  weight  tires  out  the  muscles  which  hold  the  head 
of  the  humerus  against  the  chest;  and  as  soon  as  it  is  drawn  out  to 
the  region  of  the  glenoid  process,  it  slips  into  its  socket  spontaneously. 

3.  Malgaigne's  Method  (1855)  is  the  reverse  of  Stimson's:  The 
patient  lies  on  the  sound  side  on  the  floor,  and  a  robust  assistant 
pulls  vertically  upward  on  the  dislocated  extremity,  till  the  shoulders 
just  clear  the  floor,  and  maintains  this  traction  till  the  patient's 
axillary  muscles  are  exhausted;  the  surgeon  then  pushes  the  head 
of  the  bone  into  place. 

]Many  other  modifications  of  this  principle  have  been  devised,  and 
constantly  are  being  reinvented  by  ingenious  surgeons. 

In  ijostcrior  dislocations  upon  the  cadaver  I  have  succeeded  in 
securing  reduction  by  reversing  the  manipulations  of  Kocher's  and 
Smith's  methods;  but  usually  in  life  the  capsule  is  so  widely  torn 
that  the  luxation  is  easily  reduced  by  direct  pressure  forward  or  very 
slight  manipulation. 

After  reduction,  the  arm  is  dressed  in  the  Velpeau  position  and 
guarded  use  may  be  permitted  after  two  weeks.  It  is  possible  that 
if  reduction  were  accomplished  more  often  by  manipulation  and  less 
often  by  brute  force  less  disability  as  the  result  of  periarthritis  would 
follow  this  injury.  Yvert  (1911)  has  studied  the  statistics  of  various 
surgeons  and  finds  that  65  per  cent,  of  the  patients  had  persistent 
disability,  22  per  cent,  had  fairly  satisfactory  function,  and  only 
13  per  cent,  had  excellent  results. 

Elbow. — The  typical  dislocation  at  the  elbow  consists  in  backward 
displacement  of  both  bones  of  the  forearm;  anterior  dislocation  of  both 
bones  is  rare;  and  lateral  dislocations  usually  are  incomplete  and  often 
accompanied  by  fracture  of  one  or  other  of  the  humeral  condyles. 

Posterior  Dislocation, — Posterior  dislocation  is  most  frequent  from 
fifteen  to  thirty  years  of  age,  and  results  almost  invariably  from  a 
fall  on  the  out-stretched  hand  causing  hyperextension  of  the  elbow, 
the  olecranon  acting  as  a  fulcrum  and  prying  the  bones  apart;  the 


400 


INJURIES  OF  JOINTS 


anterior  capsule  is  ruptured,  and  the  internal  lateral  ligament  more 
or  less  lacerated,  and  detachment  of  the  epitrochlea  of  the  humerus 
often  occurs.  Fracture  of  the  olecranon  by  compression  sometimes 
is  seen,  and  occasionally  the  coronoid  process  is  broken  off. 


Fig.  402. — Old  unreduced  posterior  dislocation  of  elbow,  with  evidences  of  hypertrophic 
arthritis.     Episcopal  Hospital. 


Symjjfoms. — The  deformity  usually  is  ciuite  apparent.  The  fore- 
arm, usually  pronated,  is  carried  at  an  obtuse  angle  with  the  arm, 
and  motion  is  painful  and  restricted.  The  radius  and  ulna  may  be 
displaced  directly  backward,  but  often  there  is  also  slight  lateral 
displacement.  The  olecranon  is  found  displaced  posteriorly  and 
upward  in  relation  to  the  condyles,  and  the  greater  sigmoid  fossa 
of  the  ulna  often  can  be  felt  between  the  tense  triceps  and  posterior 
surface  of  the  humerus  (Fig.  402).  The  head  of  the  radius  is  absent 
from  its  normal  place  just  in  front  of  the  external  condyle  and  can 
be  felt  posteriorly.  Anteriorly  the  lower  extremity  of  the  humerus  fills 
the  flexure  of  the  elbow.  The  diagnosis  from  supracondylar  fracture, 
referred  to  at  p.  341,  should  present  no  difficulties,  and  in  case  of 
doubt,  the  lesion  is  much  more  likely  to  be  a  fracture  than  a  dis- 
location. If  the  lesion  is  recognized,  and  the  luxation  promptly 
reduced,  recovery  is  rapid,  and  in  most  cases  nearly  perfect  function 
is  secured. 

Treatment. — In  recent  cases,  especially  in  children,  reduction 
without  an  anesthetic  is  easy,  by  reversing  the  steps  by  which  the 
lesion  was  produced:  first  hyperextend  the  elbow,  until  the  tip  of 


DISLOCATION  OF   THE  ELBOW 


401 


the  olocraiion  strikes  the  humerus,  and  the  coronoicl  is  freed  from  the 

trochlea;   tiien   make   extension   and   counter-extension   in   the   axis 

of  the  arm,  pushing  the  lower  end  of  the  humerus  backward;  and 

finally  acutely  flex  the  elbow,  when  the  bones  will  be  replaced  with  a 

snap.     Often  the  pressure  of  the 

thumbs  over  the  lower  end  of  the 

humerus,  and  that  of  tlie  clasped 

fingers  over  the  posterior  surface 

of  the  olecranon,  is  sufficient  to 

secure  reduction  (direct  method); 

or  the  knee  may  be  placed  in  the 

bend  of  the  elbow  and  used  as  a 

fulcrum  to  lever  the  bones  of  the 

forearm  away  from  the  humerus 

by  traction  on  the  wrist  with  one 

hand,  while  the  humerus  is  pushed 

backward    with    the    other    hand 

(Fig.  403).    The  elbow  is  dressed 

in   hyperflexion    (p.   347),    for    a 

week,   and  then  carried  in  a  sling  for  another,  and  after  two  weeks 

guarded  active  use  is  encouraged. 

Lateral  Dislocation. — External  dislocation  often  is  due  to  direct 
violence,  usually  is  incomplete  and  complicated  by  fracture  of  the 
external  condyle,  and  extensive  rupture  of  the  internal  lateral  ligament 


Fig.  403. — Mechanism 
po.sterior  di.slocatioii  of  i 
the  knee. 


of  reduction   of 
;lljow    by  aid  of 


Fig.  404. — External  lateral  disloca- 
tion of  elbow,  with  fracture  of  external 
condyle,  and  rupture  of  internal  lateral 
ligament  and  fracture  of  epitrochlea. 
Dr.  W.  Walker's  case.  Episcopal 
Hospital. 


Fig.  40.5. — Inward  dislocation  of  ulna  and 
radius.  Dr.  De  Tar's  case.  Patient  fell  and 
while  lying  on  left  elbow  train  struck  him 
upon  buttocks.  Reduction  easy  under  anes- 
thetic. 


(Fig.  404).  Internal  dislocation  is  rarer  than  external,  and  fracture  is  a 
less  usual  complication  (Fig.  405).  In  both  forms  the  deformity  is 
so  extreme  and  the  bony  processes  so  easily  palpable  that,  if  careful 
examination  is  made  before  swelling  obscures  the  landmarks,  the 
26 


402 


IXJCRIES  OF  JOINTS 


diagnosis  should  not  be  difficult.  Reduction  is  easier  to  secure  than 
to  maintain,  especially  if  fracture  exists.  The  elbow  should  be  dressed 
in  hyperflexion  and  treated  as  a  fracture. 

Forward  Dislocation. — Forward  dislocation  of  both  bones  at  the 
elbow  is  very  rare;  even  including  seven  cases  in  which  the  olecranon 
was  broken  off  and  remained  in  place,  the  total  number  on  record, 
according  to  Stimson,  is  less  than  twenty-five.  Fracture  of  the  epi- 
trochlea  is  a  frequent  accompaniment.  Reduction  is  not  difficult,  as 
both  lateral  ligaments  are  lacerated. 

Dislocation  of  the  Ulna  Alone  from  the  humerus  is  most  often  pos- 
terior; the  symptoms  and  treatment  are  much  the  same  as  when  both 
bones  are  so  displaced. 


Fig.  406. — Anterior  and  outward  dislocation  of  head  of  radius,  with  fracture  of 
shaft  of  ulna.     Four  months  after  injury.     Episcopal  Hospital. 


Dislocation  of  the  Head  of  the  Radius  usually  occurs  in  an  anterior 
direction.  The  orbicular  ligament  may  remain  intact,  the  radius 
slipping  out  of  its  grasp,  and  subsequently  being  displaced  forward 
by  the  pull  of  the  biceps;  often  it  is  the  result  of  a  fracture  of  the 
upper  part  of  the  shaft  of  the  ulna,  from  direct  violence,  the  con- 
tinuance of  the  fracturing  force  driving  the  head  of  the  radius  forward 
(Figs.  40(3  and  407).  This  combined  lesion  is  so  freciuent  that  the 
recognition  of  either  a  dislocation  of  the  radial  head  or  a  fracture  of  the 
upper  end  of  the  ulna  should  make  the  surgeon  suspect  the  existence 
of  the  complicating  lesion.  Examination  may  detect  a  hollow  in  front 
of  the  external  condyle,  and  the  head  of  the  radius  a  little  forward 
from  its  normal  position;  flexion  of  the  elbow  beyond  a  right  angle  may 
be  prevented  by  contact  of  the  radius  with  the  humerus.  Reduction 
sometimes  may  be  secured  by  full  supination  and  direct  pressure 
upon   the  displaced  bone;   and  flexion  will  then  become  possible. 


DISLOCATION  OF   THE    WRIST 


403 


Reduction  sliould  he  obtained  at  all  hazards,  l)y  arthrotomy  it'  neces- 
sary. Only  after  reduction  of  the  radial  flislocation  has  heen  secured 
can  the  fracture  of  the  ulna  he  reduced.  If  re-dislocation  of  the  radial 
head  occurs  after  keepin<;  the  elbow  hyperflexed  (p.  ?A1)  for  several 
weeks,  it  may  be  assumed  that  the  radial  head  had  not  been  replaced 
within  the  orbicular  lijjament;  and  an  operation  may  be  necessary 
to  hold  it  in  i>lace.  In  cases  of  complete  dislocation  it  is  very  unlikely 
that  reduction  can  be  secured  without  operation.  In  old  unreduced 
luxation,  excision  of  the  radial  head  may  be  done  to  permit  flexion 
of  the  elbow,  but  in  children  this  should  be  avoided  if  possible,  since 
removal  of  the  ei)ii)hysis  will   interfere  with  development. 


Fig.  407. — Anterior  and  outward  dislocation  of  head  of  radius,  three  months  after 
reduction  by  arthrotomy  and  capsulorrhaphy.     Episcopal  Hospital. 


In  young  children  a  subluxation  known  as  "pulled  elbow"  occurs: 
this  is  due  to  vertical  traction  on  the  forearm,  often  produced  as  the 
caretaker  helps  or  lifts  the  child  across  an  obstruction  in  the  street.  If 
the  forearm  is  supinated  the  vertical  traction  tends  to  bring  the  fore- 
arm and  arm  into  a  straight  line,  causing  momentary  loss  of  the  carry- 
ing angle;  or  forced  pronation  may  pry  the  radius  forward  over  the 
ulna  as  a  fulcrum.  Symptoms  of  pulled  elbow  are  rather  indefinite, 
and  in  many  cases  no  definite  history  of  trauma  can  be  obtained;  it 
is  merely  noticed  that  the  arm  is  not  used  properly,  and  that  there  is 
tenderness  around  the  elbow.  Treatment  of  "pulled  elbow"  consists 
in  securing  reduction  of  the  subluxated  bone  by  the  same  methods 
employed  in  cases  of  complete  dislocation,  and  in  preventing  recurrence 
(which  is  not  very  rare)  by  keeping  the  elbow  at  rest  for  a  week. 

Wrist. — Dislocation  of  the  radio-carpal  joint,  usually  consisting 
in  dorsal  displacement  of  the  carpus,  is  very  rare;  Stimson  classes 
Barton's  fracture  (p.  355)  more  as  a  complication  of  this  dislocation 
than  as  an  independent  lesion.  It  is  produced  usually  by  the 
same  injuries  as  Colles's  fracture,  and  the  differential  diagnosis  is 


404 


INJURIES  OF  JOINTS 


not  always  easy;  but  if  it  is  possible  to  feel  the  styloid  processes  of 
the  radius  and  ulna  still  attached  to  their  respective  bones,  and  to 
ascertain  that  the  length  of  the  bones  of  the  forearm  remains  the  same 
on  both  sides  of  the  body  and  to  feel  the  very  abrupt  eminence  on 
the  dorsum  caused  by  the  displaced  carpal  bones,  confusion  between 
fracture  and  dislocation  is  not  apt  to  occur.  Besides,  the  luxation 
is  reduced  by  an  elastic  snap,  without  crepitus,  and  without  tendency 
to  recurrence.  I  have  seen  one  case  myself,  easily  diagnosed  clinically 
by  attention  to  these  details.  The  diagnosis  may  be  confirmed  by 
a  skiagraph. 

Spontaneous  Siihhi.ratiun  of  the  Wrist  {Madelumfs  Disease). — See 
p.  542. 

Dislocations  of  the  carpal  hones  are  not  very  uncommon,  particularly 
forward  dislocation  of  the  semilunar,  associated  or  not  with  fracture 
of  the  scaphoid.  The  bone  is  palpable  under  the  flexor  tendons, 
and  there  is  a  gap  on  the  extensor  surface  between  the  os  magnum 
and  radius.  The  other  carpal  bones,  most  often  scaphoid  or  os  mag- 
num, usually  are  dislocated  backward.  If  reduction  is  not  easily 
secured,  the  displaced  bone  should  be  excised. 

Metacarpus. — The  metacarpal  bones  rarely  are  luxated,  the  dis- 
placement usually  being  posterior. 

Phalanges.— The  proximal  phalanx  of  the  thumb  not  infreciuently  is 
dislocated  posteriorly  on  the  head  of  its  metacarpal  bone  by  hyper- 
extension,  sometimes  in  a  fight, 
a  fall,  or  in  the  effort  to  push 
a  tight  stocking  off  the  heel  of 
the  foot.  The  deformity  is 
quite  characteristic  (Fig.  408), 
the  phalanx  in  well-marked 
cases  making  a  distinct  angle 
with  the  metacarpal  bone,  the 
head  of  which  is  easily  palpable 
in  front;  the  distal  phalanx 
remains  flexed,  owing  to  ten- 
sion on  the  flexor  longus  pol- 
licis,  which  is  displaced  to 
one  side  or  other,  usually 
the  ulnar  side  of  the  metacarpal.  The  head  of  the  metacarpal  is 
"button-holed"  through  the  anterior  ligament;  the  tendons  of  the 
flexor  brevis  blend  with  the  lateral  ligaments,  and  it  is  the  tension  of 
these  lateral  ligaments,  which  fit  like  a  collar  around  the  neck  of  the 
metacarpal,  that  may  render  reduction  impossible.  In  some  cases 
reduction  can  be  effected  without  anesthesia,  (1)  by  pressing  the 
metacarpal  bone  toward  the  palm,  so  as  to  relax  the  short  thumb 
muscles;  (2)  by  sliding  the  base  of  the  phalanx  over  the  head  of  the 
metacarpal,  keeping  the  phalanx  in  hyperextension  until  the  head  of 
the  metacarpal  has  been  cleared.  If  reduction  is  impossible,  an 
incision  is  made  along  the  radial  border  of  the  flexor  surface  of  the 


Fig.  408. — Dislocation  of  metacarpo-phalan- 
geal  joint  of  thumb.  Reduced  by  arthrotomy. 
Episcopal  Hospital. 


DISLOCAriON   OF   THE   HIP 


40.") 


j)r()iniii(Mit   liciid  of  the  tliuml)  iiictacarpiil,  :iih1   tlic  cxtcriKil  liitcnil 
li<,Miiu'nt  is  (li\i(lc(l  close  to  the  pluihiiix. 

J)i,s'locaii(m.s  of  tlir  inlrriihdhiiKjnd  johils  of  the  lingers  almost 
always  takes  place  posteriorlx ,  from  li\  iMTextensioii,  in  falls  or  l)lo\vs 
on  tiie  fin<,'er  tips  (V\^.  4()i»).  Hediiction  usually  is  easy,  but  a  joint 
fracturi'  of  the  i)roxinial  hone  may  exist,  and  some  deformity  may 
result.  Treatment  is  the  same  as  for  fracture  of  a  i)halanx.  Jjitrntl 
dislocation  usually  is  ineom])lete  (Fig.  410). 


Fig.  409. — Posterior  dislocation  of 
niitldle  phalanx  on  iiroximal  of  fifth 
finger.     Episcopal  Hosijital. 


Fig.  410. — Lateral  dislocation  of  mid- 
dle on  proximal  phalanx.  Episcopal 
Hospital. 


Sacro-iliac  Joints. — ('omplete  luxation  is  rare,  hut  subluxation, 
from  sprain  or  long-continued  strain  is  not  unusual.  ^Motion  occurs 
antero-posteriorly  around  a  transverse  axis,  and  the  usual  displace- 
ment is  of  the  upper  end  of  the  sacrum  backward.  Cricks  and  stitches 
in  the  small  of  the  back,  or  severe  backache  may  follow  strain  on 
these  joint  ligaments  from  stooping,  from  malposition  in  sitting  or 
standing,  or  simply  from  lying  long  flat  on  the  back,  when  the  mus- 
cular support  is  weakened  by  anesthesia  or  constitutional  disease. 
Relaxation  of  these  joints  sometimes  is  seen,  and  is  best  treated  by 
orthopedic  apparatus,  gymnastics,  etc.  (p.  535). 

Hip. — Dislocation  of  the  hip  is  a  rare  and  rather  a  serious  injury. 
The  head  of  the  femur  is  held  in  the  acetabulum  by  a  capsular  ligament 
which  is  reinforced  above  and  below  by  l)and-like  ligaments,  leaving 
the  capsule  weak  anteriorly  and  posteriorly.  The  upper  band-like 
ligament  (ilio-femoral  ligament  of  Bertin,  1754)  is  especially  strong, 
and  is  known  as  the  Y-ligament  of  Bigelow^  (1869);  it  is  scarcely 
ever  ruptured,  no  matter  what  the  force  that  produces  the  luxation. 
Indirect  violence  is  the  usual  cause,  the  femur  being  forced  beyond 
its  normal  range  either  in  flexion  and  adduction,  or  in  extension  and 
abduction,  and  the  head  of  the  bone  being  pried  out  of  the  acetabulum 
by  leverage.  In  the  cadaver  luxations  are  most  easily  produced  by 
hyperabduction,  forcing  the  great  trochanter  against  the  posterior 
lip  of  the  acetabulum,  and  using  it  as  a  fulcrum  by  which  the  head  is 
lifted  out  of  its  socket;  the  capsule  is  then  ruptured  anteriorly  below 
the  ilio-femoral  ligament,  and  the  head  of  the  bone  passes  on  to  the 
anterior  plaiie^  of  the  innominate  bone  (Fig.  411).    In  patients,  how- 

1  Nekton's  line  divides  the  innominate  bone  into  two  planes  (Alli.s,  1S96). 


406 


INJURIES  OF  JOINTS 


Fk;.  411. — Innominate  bone  showing  the 
anterior  and  posterior  planes.  University  of 
Pennsylvania. 


ever,  the  history  of  the  injury  generally  indicates  another  mechanism, 
the  femur  having  been  in  flexon  and  adduction,  and  the  force  having 
been  received  through  an  upward  thrust  in  the  long  axis  of  the  femur, 
or  by  a  heavy  weight  falling  on  the  pehis  from  behind.  In  such 
cases  it  is  probable  that  the  strong  ilio-femoral  ligament  has  been 
wound  around  the  neck  of  the  femur  (inwardly  rotated),  acting  as  a 

sliding  fulcrum;  or  possibly 
that  the  neck  of  the  femur 
has  been  forced  against  the 
horizontal  ramus  of  the  pubis, 
and  that  the  head  has  been 
pried  out  of  the  acetabulum 
over  thi^  as  a  fulcrum.  The 
capsule  here  is  ruptured  pos- 
teriorly, and  the  femoral  head 
passes  on  to  the  posterior 
yJane  of  the  innominate  bone. 
Owing  to  the  immense  length 
of  the  distal  arm  of  the  lever 
(the  whole  lower  extremity),  it 
is  not  at  all  unusual  for  a  dis- 
location primitively  anterior  to  be  converted  into  one  of  the  posterior 
variety  secondarily;  in  such  cases  the  capsule  may  be  widely  lacerated, 
but  in  almost  every  case  the  ilio-femoral  ligament  remains  intact,  and 
the  lower  extremity  is  circumducted  and  rotated  on  it  as  a  pivot. 

In  general,  then,  two  main  types  of  dislocation  at  the  hip  may  be 
recognized,  anterior  and  posterior;  and  of  each  type  there  are  several 
varieties,     according     as 
the    head  of    the    femur  J 

rests  high  or  low  on  the 
anterior  or  posterior 
plane  of  the  pelvis  (Fig. 
412). 

Posterior  Dislocations  of 
the  Hip,  more  frequent 
than  anterior,  are  classed 
as  high  ("dislocation  on 
the  dorsum  ilii,"  or 
"above  the  tendon"  of 
the  obturator  internus), 
and  low  ("dislocation into 
the  sciatic  notch"  of  Sir 
Astley  Cooper,  1822;  or  "below  the  tendon"  of  Bigelow  1869);  and 
of  these  two  the  high  luxation  is  much  more  frequent,  though  this 
may  be  only  a  secondary  displacement,  the  head  of  the  femur 
having  emerged  from  the  capsule  lower  than  the  sciatic  notch,  and 
having  been  displaced   upward   when   the   limb  was    extended. 


Fig.  412. — Usual  sites  of  dislocation  at  the  hip. 
A  to  B,  Nelation's  line.  Posterior  dislocations  are 
(1)  low;  (2)  high.  Anterior  dislocations  are:  (8)  low; 
(4)  high.     See  text. 


DISLOCATION  OF   THE   II W 


407 


^ynii>Uwts.-'T\\vve  is  loss  of  normal  mohility;  there  is  shortening, 
with  flexion,  addnetion  and  internal  rotation  at  the  hip;  and  in  stand- 
ing the  toes  of  the  injured  side  rest  on  the  dorsum  of  the  other  foot 
(^\^  4i:i).    The  lower  the  position  of  the  femoral  head  on  the  posterior 


Fig.  413. — Posterior  (dorsal)  dislocation  of  the  hip.     (Stinison.) 

plane,  the  more  marked  will  be  the  shortening,  flexion,  adduction, 
and  inward  rotation.  The  head  of  the  femur^  can  no  longer  be  felt 
below  Poupart's  ligament,  beneath  the  femoral  artery,  but  sometmies 

1  A  good  working  rule  to  remember  is  that  the  position  of  the  internal  condyle 
corresponds  1o  that  of  the  head  of  the  femur,  while  that  of  the  external  condyle 
corresponds  to  that  of  the  great  trochanter  (G.  G.  Davis,  1910). 


408 


INJURIES  OF  JOINTS 


can  be  detected  posteriorly  under  the  gluteal  muscles;  the  trochanter 
is  unduly  prominent,  is  rotated  forward,  and  is  above  Nekton's  line. 
Anterior  Dislocations  of  the  Hip  are  classed  as  high  ("pubic"),  or 
low  ("thyroid"),  the  latter,  in  which  the  head  rests  in  the  obturator 
foramen,  probably  being  the  primitive  form  in  most  cases;  in  the 
pubic  form,  the  head  rests  against  the  horizontal  ramus  of  the  pubis; 
an  exaggerated  form  of  the  high  dislocation  is  the  "suprapubic,"  and 
an  exaggerated  form  of^the  low  dislocation  is  the  "perineal,"  the 

head  of  the  bone  passing  inward  be- 
yond the  thyroid  foramen  and  across 
the  ischium  into  the  perineum. 

Symptoms. — ^AU  these  anterior  dis- 
locations are  characterized  by  im- 
mobility, flexion,  abduction,  and 
eversion  of  the  limb  (Fig.  414);  in 
the  low  forms  there  may  be  apparent 
lengthening,  but  in  the  high  cases 
there  usually  is  actual  shortening. 
The  head  of  the  femur  generally  can 
be  felt  beneath  the  pectineus  or  ad- 
ductor muscles,  and  often  forms  a 
visible  prominence;  the  trochanter  is 
rotated  backward,  and  is  less  promi- 
nent than  normally. 

Other  Atypical  or  "Irregular"  Dis- 
locations of  the  Hip  occur,  but  are 
extremely  rare,  and  are  either  sec- 
ondary modifications  of  those  de- 
scribed above,  or  are  caused  by  such 
\iolent  trauma  as  frequently  to  cost 
the  patient  his  life.  The  so-called 
"central  dislocation  of  the  hip"  is 
discussed  at  p.  325. 

Prognosis. — If  reduction  is  effected 
promptly,     and    without     additional 
trauma,    restoration  of    function    is 
rapid,   and   generally    complete;  but 
Pennsylvania  Hos-     the  longer  rcductiou  is  delayed,  and 
the  greater  the  force  required  in  ac- 
complishing it,  the  more  unfavorable 
the  outlook.    But  even  in  some  cases  of  irreducible  luxation,  especially 
of  the  thyroid  type,  very  fair  use  of  the  limb  may  be  secured. 

Treatment. — Reduction  of  dislocation  of  the  hip  is  accomplished 
either  by  the  direct  or  indirect  method. 

Direct  Method. — In  this,  systematized  by  Allis  (189G),  the  head  of 
the  femur  is  first  brought  into  the  position  in  which  it  burst  tlirough 
the  capsule,  and  is  then  pushed  or  pulled  into  the  acetabulum. 
As  in  both  anterior  and  posterior  dislocations  the  head  leaves  the 


Fig.  414, 
location  of   hip 
pital. 


Anterior    (thyroid) 


DISLOCATION  OF   THE   HIP 


409 


acrtabiiliim  in  its  lowor  i)art,  and  as  the  capsnlc  i)r(>l)al)Iy  is  widely 
torn  below,  the  method  ot"  direct  reposition  is  nearly  the  same  for  both 
varieties.  The  patient  should  be  anesthetized  anil  laid  on  his  back 
on  a  mattress  on  the  floor,  with  the  pelvis  firmly  fixed:  flex  the  t\\\^\\ 
on  the  pelvis  to  a  riu;ht  an<(le,  thus  brin<;inff  the  head  of  the  fenuir 
toward  the  lower  part  of  the  acetabulum;  flex  the  knee  to  a  ri<i;ht  anj,de, 
to  relax  the  hamstring  muscles  and  sciatic  nerve,  and  to  aid  in  rotating 
the  thigh.  Hold  the  ankle  with  one  hand,  and  pass  the  other  hand 
beneath  the  flexed  knee  or  sling  a  towel  under  the  knee  and  over  your 
own  shoulders,  to  aid  in  the  upward  traction  required.  In  hackifard 
dislocation  have  the  thigh  slightly  adduried,  to  free  the  head  from 
the  rim  of  the  aceta])ulum  and   to  relax  the  anterior  branch  of  the 


Fig.  415. — Position  of  bones  in  reduction  of  posterior  dislocation  of  hip  by  direct 
method.     University  of  Pennsylvania. 

Y-ligament;  then  make  vertical  traction  on  the  thigh  upward  and 
a  little  imcard,  and  the  head  may  jump  into  the  acetabulum  (Fig. 
415).  If  it  does  not,  rotate  the  thigh  gently  in  and  out  (do  not 
circumduct  it),  to  make  the  capsule  gape  widest,  and  try  to  pull 
the  head  over  the  rim  of  the  acetabulum  in  the  various  positions 
of  rotation.  An  assistant  may  help  by  direct  pressure  upward 
and  inward  on  the  great  trochanter.  The  head  usually  will  jump 
into  the  acetabulum  with  an  audible  snap.  In  forward  dislocation, 
have  the  thigh  slightly  abducted,  to  free  the  head  from  the  antero- 
inferior margin  of  the  acetabulum,  and  to  relax  the  posterior  branch 
of  the  Y-ligament;  then  make  vertical  traction  upward  and  slightly 
outward,  and  the  head  often  will  jump  into  the  acetabulum  (Fig.  41()). 
If  not,  gentle  rotation  may  be  tried,  until  the  capsule  gapes  its  widest; 


410 


INJURIES  OF  JOINTS 


and  an  assistant  may  aid  by  pushing  the  trochanter  upward  and 
slightly  outward. 

In  Stimson's  application  of  the  direct  method  (1889)  for  posterior 
dislocation,  the  patient  lies  prone,  with  the  affected  thigh  hanging 
vertically  downward:  the  knee  of  the  dislocated  side  is  flexed,  and 
the  ankle  held  by  the  surgeon;  in  most  cases  the  weight  of  the  limb 
is  sufficient  to  reduce  the  dislocation  within  a  few  minutes  without 
pain  and  almost  imperceptibly;  if  necessary,  weight  may  be  added  t<j 
the  knee,  and  gentle  rotation  practiced,  as  when  the  patient  lies  on 
his  back. 


Fig.  416. — Position  of  bones  in  reduction  of  anterior  dislocation  of  hip  by  direct 
method.     University  of  Pennsylvania. 


Indirect  Method. — Reduction  by  manipulation  alone  was  taught 
and  practised  by  Hippocrates,  N.  R.  Smith  (1831),  and  Despres 
(1835),  and  was  systematized  by  ^Y.  W.  Reid  (1851);  they  regarded 
the  muscles  as  the  chief  ob.stacles  to  reduction;  but  it  remained  for 
Moses  Gunn  (1853)  and  especially  for  Bigelow  (1869)  to  demonstrate 
that  even  wdth  muscular  contraction  abolished  by  anesthesia,  the 
capsule  still  remained  the  supreme  obstacle,  and  that  manipulation 
was  successful  only  when  the  action  of  the  Y-ligament  was  appreciated 
and  employed  as  an  aid.  It  is  used  as  a  sliding  fulcrum  over  which 
the  head  of  the  femur  rides  into  the  acetabulum.  The  patient  is 
anesthetized,  and  laid  on  his  back  on  a  mattress  on  the  floor;  with 
the  pelvis  firmly  fixed,  the  thigh  is  flexed  on  the  pelvis  to  relax  the 
Y-ligament  and  to  bring  the  head  of  the  bone  down  to  the  lower 
part  of  the  acetabulum  near  the  rent  in  the  capsule;  and  the  leg  is 


DISLOCATION  OF   THE   11 W 


411 


flexed  on  the  X\\'v^\\  to  aid  in  the  nianipnhition,  and  to  rehix  the  ham- 
strings and  seiatie  ner\e.  In  po.strrior  diskx-ations  tlie  linih  is  l)rouglit 
up  in  the  position  in  which  it  is  found  (adduction),  and  is  gently  circum- 
ducted and  rotated  outward  after  the  thigh  lias  been  flexcfl  to  more 
than  a  right  angle  with  the  pelvis;  as  outward  circumduction  is  con- 
tiiuied  (Fig.  417),  the  head  of  the  hone  is  swung  downward  and  inward 
by  tension  on  the  posterior  branch  of  the  Y-ligament,  and  linally 
as  the  limb  is  brought  down  to  the  position  of  full  extension  and 
very  slight  abduction,  the  head  rides  over  the  rim  of  the  acetabulum 
ami  sinks  into  its  socket.  If  the  abduction  is  too  great  as  the  thigh  is 
brought  down  to  extension,  the  head  will  slide  across  to  the  anterior 
plane  of  the  pelvis,  and  a  secondary  thyroid  luxation  will  be  produced. 
Rarely  in  this  excursion  the  sciatic  nerve  may  be  caught  up  over  the 
neck  of  the  femur.  If  abduction  is  not  great  enough,  the  head  will 
slide  up  again  on  the  outer  side  of  the  acetabulum,  and  the  high 
posterior  luxation  will  be  reproduced.    Rarely  as  it  slides  up  it  may 


Fig.  417. — Reduction  of  backward  dis- 
location of  femur.     (Bigelow.) 


Fig.    418. — Reduction    of    downward    and 
forward  dislocation  of  femur.   (Bigelow.) 


catch  under  the  tendon  of  the  obturator  internus.  In  anterior  dis- 
locations the  limb  is  brought  up  in  the  position  in  which  it  is  found 
(abduction),  and  is  gently  circumducted  and  rotated  inw^ard  after 
the  thigh  has  been  flexed  to  more  than  a  right  angle  with  the  pelvis; 
as  inward  circumduction  is  continued  (Fig.  41 S),  the  head  of  the  bone 
is  swung  downward  and  outward  by  tension  on  the  anterior  l)ranch 
of  the  Y-ligament;  and  finally  as  the  limb  is  brought  down  to  the 
position  of  full  extension  and  very  slight  adduction,  the  head  rides 
over  the  rim  of  the  acetabulum  into  its  socket.  If  the  addvction  is 
too  great,  a  secondary  posterior  dislocation  may  be  produced;  and 
if  it  i^  7iot  great  enough,  the  head  will  slide  up  the  inner  side  of  the 
acetabulum  to  a  pubic  position. 

Reduction  is  known  to  have  been  accomplished  when  the  head 
of  the  bone  is  felt  to  snap  into  place,  and  it  can  be  felt  rotating  in 
its  socket  by  the  fingers  below  Poupart's  ligament;  when  normal 
extension  of  the  hip  is  possible,  and  when  a  skiagraph  shows  the 
bones   in   place. 


412 


rXJURIES  OF  JOINTS 


Ajter-ireaiment. — The  patient  should  be  kept  in  bed  with  moderate 
weight-extension  for  a  couple  of  weeks,  and  should  resume  use  of 
the  limb  with  caution. 
Patella. — See  page  279. 

Knee. — Traumatic  luxations  of  the  knee  are  extremely  rare,  and 
usually  caused  by  very  severe  injuries.  The  displacement  of  the 
head  of  the  tibia  may  be  backward,  forward,  lateral,  or  rotatory. 
Wise  (1909j  refers  to  270  cases  of  dislocation  of  the  knee,  114  of  which 
were  anterior.  Most  of  the  displacements  are  incomplete,  the  lateral 
almost  invariably.  Forward  dislocation  is  caused  by  sudden  violent 
hj-perextension,  by  indirect  or  direct  violence;  the  tibia  slides  up 
on  the  front  of  the  condyles,  but  usually  maintains  the  same  axis 
as  the  femur,  not  being  flexed  or  hyperextended.  Backward  dis- 
location usually  follows  direct  force  applied  to  the  front  of  the  tibia, 
and  the  leg  becomes  hyperextended  on  the  tliigh.  In  many  of  these 
luxations  injuries  to  the  popliteal  vessels  or  nerves  are  present,  and 
the  intra-articular  cartilages  and  ligaments  may  be  ruptured.  Usually 
reduction  is  not  very  difficult,  owing  to  stretching  or  laceration  of 
the  lateral  ligaments.  Prognosis  as  to  function  is  not  very  good 
even  in  uncomplicated  cases,  some  deformity  fflexion,  valgus,  etc.), 
generally  persisting  through  life;  and  for  complications,  amputation 
may  be  required. 

Fracture  or  Subluxation  of  the  Semilunar  Cartilages  Internal  De- 
rangement oj  the  Knee-joint,  Hey,  1S03).     In  these  cases  there  may 

be  a  sprain,  or  slight  twist  of  the  knee, 
which,  while  the  patient  is  walking,  sud- 
denly becomes  locked  in  a  flexed  position; 
at  the  same  time  excruciating  pain  may 
be  felt,  and  sometimes  a  palpable  lump 
appears  below  the  internal  condyle.  The 
lesion  usually  consists  in  detachment  of 
the  internal  semilunar  cartilage  from  the 
head  of  the  tibia;  sometimes  a  piece  of  it 
is  broken  off,  and  slipping  outward,  locks 
the  knee-joint.  As  a  rule  gentle  mani- 
pulation and  gradual  passive  extension 
-o  far  as  possible,  followed  by  sudden 
acute  flexion  of  the  knee  will  reduce  the 
deformity,  and  restore  the  movements  of 
the  joint.  The  same  train  of  symptoms, 
however,  frequently  recurs,  and  may  be 
due  not  to  detachment  or  fracture  of  a 
cartilage,  but  to  the  presence  of  "joint 
mice"  (p.  461),  the  result  of  chronic 
articular  disease. 
Treatment. — After  reduction  of  the  deformity  some  appliance  must 
be  worn  to  limit  motion  in  the  knee,  and  to  prevent  rotation.  If 
the  patient  is  anxious  for  a  radical  cure,  arthrotomy  may  be  done 


Fig.  419. — External  semilunar 
cartilage  removed  from  knee,  for 
dislocation.   Episcopal  Hospital. 


DISLOCATION  OF   THE   ANKLE 


413 


preferably  tlir()iijj;h  a  transverse  incision  directly  over  the  luxated 
cartilaj^e,  which  is  caught  in  a  shar{)  hook  or  volsellum  forceps  and 
renio\e(l  (i'^ii;:.  415)).  Attempts  to  suture  it  in  i)lace  are  not  advisable. 
Function  nearly  always  is  completely  restored.  Arthrotomy  for  the 
removal  of  "joint  mice"  is  best  done  by  a  longitudinal  incision  along 
the  inner  border  of  the  patella,  whicli  may  then  be  displaced  outward, 
as  the  knee  is  Hexed,  widely  exposing  the  joint. 


Fig.  420T — Skiacraph  of  fracture-dislocation  of  astragalus.  Age  forty-five  years. 
From  fall  of  eight  feet,  landing  on  feet.  Irreducible.  Both  fragments  excised.  Excel- 
lent result.     Episcopal  Hospital. 


Ankle.  (Tibiu-tarsal  Joint). — Except  in  connection  with  fracture 
of  the  leg  bones,  dislocations  at  the  ankle-joint  are  exceedingly  rare. 
Wendel  (1898)  collected  108  cases  without  fracture.  Posterior  luxa- 
tion usually  follows  forced  plantar  flexion  of  the  foot,  with  rupture 
of  the  lateral  ligaments  of  the  ankle,  the  astragalus  sliding  backward 
oflf  the  tibio-fibular  mortise  as  dorsal  flexion  is  regained.  Anterior 
luxation,  much  rarer,  usually  occurs  when  the  foot  is  in  extreme 
dorsal  flexion,  the  leg  bones  being  forced  backward  against  the  tense 
tendo  Achillis  either  by  a  blow  from  above  or  by  a  fall  on  the  heel. 
Lateral  dislocation  is  that  in  which  the  astragalus  and  with  it  the 
foot,  leaves  the  tibio-fibular  mortise,  and  is  displaced  externally  or 
internally,  there  being  little  or  no  rotation  of  the  foot.  A  less  unusual 
displacement  is  that  in  which  the  astragalus  rotates  around  an  antero- 
posterior axis,  so  that  the  sole  of  the  foot  looks  either  inward  (supina- 
tion dislocation)  or  outward  {pronation  dislocation).  If,  on  the  other 
hand,  the  astragalus  rotates  around  a  vertical  axis,  it  may  remain 


414 


INJURIES  OF  JOINTS 


in  the  tibio-fibiilar  mortise,  but  the  entire  foot  may  rotate  with  it 
the  toes  looking  inward  and  the  heel  outward  in  (Ushcation  hy  inver- 
sion, and  the  opposite  being  the  case  in  dislocation  by  cversion.  Dis- 
location iqncard  (the  astragalus  separating  the  tibia  and  fibula)  is 
known  by  Nelaton's  name,  though  his  case  was  complicated  by 
fracture.  Unless  swelHng  obscures  bony  landmarks,  these  various 
forms  can  be  distinguished  clinically;  but  in  all  cases  it  is  desirable 
to  have  skiagraphs  made  in  at  least  two  planes.  These  dislocations 
about  the  ankle-joint  frequently  are  compound,  and  as  already 
remarked,  fracture  of  some  of  the  bones  involved  very  rarely  is 
absent  (Fig.  384).  Reduction  is  not  always  possible  without  incision, 
and  should  be  accomplished  on  the  day  of  injury  if  possible.  The 
longer  the  bones  remain  out  of  place,  the  less  favorable  will  be  the 
prognosis  for  function. 


Fig.  421. — Skiagraph  of  upward  dislocation  of  tarsal  scaphoid.     Age  fifty-four  years. 

Episcopal  Hospital. 

Tarsus. — The  astragalus  may  be  the  subject  of  an  isolated  dis- 
location forward  or  backward,  the  latter  being  much  rarer,  and  the 
forward  displacement  usually  being  somewhat  inward  or  outward 
as  well;  or  the  astragalus  may  be  rotated  in  any  axis,  remaining  in 
situ.  If  reduction  is  not  possible  by  manipulation,  aided  perhaps 
by  tenotomy  of  the  tendo  Achillis,  arthrotomy  should  be  done,  and 
the  astragalus  removed  unless  reduction  is  easy.  Good  function 
followed  astragalectomy  for  fracture-dislocation  in  the  case  repre- 
sented in  Fig.  420.     Isolated  dislocation  of  the  other  tarsal  bones 


DISLOCATION  OF   THE  FOOT 


415 


may  occur  (Fig.  421);  unless  reduction  is  easy,  the  displaced  bone 
should  1)C  excised.  Siiha.s-lraguldr  (Usioration  of  the  foot,  of  which 
Wise  (1909)  has  collected  S7  examples  (oO  inward,  21  outward, 
S  anterior,  and  <S  posterior),  consists  of  displacement  of  the  entire 
foot  from  the  astrajjjalus,  which  remains  in  the  tibio-fibuiar  mortise. 
Reduction  usually  is  possible  by  manipulation,  and  may  be  aided 
by  tenotomy  of  the  tibialis  anticus,  or  by  incision,  if  necessary.  For 
compound  dislocations  amputation  may  be  required. 

Dislocation  at  the  mcdio-tarsal  joint  is  rare.  Skillern  (191.'i)  reports 
what  he  considers  the  thirteenth  authentic  case  on  record.     The 
anterior  tarsus  may  be  displaced  toward 
the  flexor  or  extensor  surface.     Reduction 
usually  is  possible  by  manipulation  under 
an  anesthetic. 

Metatarsus. — Dislocations  of  the  meta- 
tarsals have  been  studied  at  length  by 
Quenu  and  Kiiss  (1909);  they  collected 
35  cases,  and  believe  that  systematic 
radiographic  study  will  show  it  to  be 
rather  a  freciuent  lesion  of  the  foot.  It 
frequently  is  complicated  by  fracture,  and 
usually  is  due  to  direct  violence  or  to 
falls  on  the  toes.  They  show  that  the 
foot  may  be  divided  into  two  structural 
parts,  as  in  Fig.  422,  of  which  the  main 
weight-bearing  part  is  composed  of  the 
tarsus  and  the  first  metatarsal  with  its 
phalanges,  while  the  four  outer  meta- 
tarsals serve  as  a  balance.  The  most 
frequent  luxations  are  (1)  one  in  which 
the  balancing  portion  is  displaced  exter- 
nally and  toward  the  dorsum  of  the  foot 

(external  dorso-lateral  dislocation) ,  and  (2)  one  in  which  there  is  a  dis- 
placement of  the  balancing  portion  outward  and  of  the  first  meta- 
tarsal inward  (divergent  dislocation).  Diagnosis  depends  largely  on 
radiography.  If  reduction  is  impossible  by  manipulation,  operation 
may  be  done;  this  cannot  be  made  to  conform  to  any  type,  but  may 
involve  tenotomy,  arthrodesis,  removal  of  fragments,  etc.  But  even 
in  cases  not  reduced,  fair  use  of  the  foot  may  be  regained  after 
scA'eral  months  or  a  year. 

Phalanges. — Dislocation  of  the  phalanges  of  the  toes  are  rare, 
usually  due  to  direct  violence,  and  hence  often  compound.  Reduction 
and  treatment  are  the  same  as  in  the  fingers. 


Fig.  422. — The  structural  por- 
tions of  the  foot  concerned  in 
metatarsal  dislocations.  (Quenu 
and  Kiiss.) 


CHAPTER  XIV. 
DISEASES  OF  BONE. 

DYSTROPHIES  OF  BONE. 

There  are  numerous  affections  of  bone  of  whose  nature  patholo- 
gists are  still  in  ignorance.  Some  of  them  are  known  to  be  associated 
with  changes  in  the  organs  of  internal  secretion;  some  of  them  may 
be  due  to  remote  infections,  to  chronic  toxemias  or  intoxications; 
but  all  that  is  certain  is  that  they  depend  on  disturbances  of  nutri- 
tion, and  for  that  reason  it  is  convenient  to  group  them  together  as 
dystrophies.  In  most  cases  the  osseous  system  alone  is  not  affected, 
but  is  more  conspicuously  diseased  than  the  soft  tissues.  The  diseases 
in  question  range  from  atrophic  to  hypertrophic  forms,  but  in  many 
both  atrophy  (softening)  and  hypertrophy  (hardening)  are  present 
coincidently,  or  at  different  stages  of  the  same  disease.  Congenital 
malformations  are  mentioned  in  the  chapter  on  Orthopedic  Surgery 
(Chapter  XVI). 

Atrophy  of  Bone. — This  may  be  concentric  or  eccentric  (Fig.  423).  In 
the  former  variety,  which  begins  at  the  periosteal  surface,  the  size  of 
the  bone  decreases,  but  its  length  (due  to  cartilaginous  growth)  is 
little  affected,  and  what  once  was  a  strong  shaft  becomes  a  mere 
spindle.  In  eccentric  atrophy  the  changes  begin  in  the  marrow, 
and,  though  the  bone  may  not  change  in  size,  it  becomes  weaker 
and  more  porous.  In  both  forms  the  pathological  changes  consist 
in  absorption  of  the  bony  trabecule  by  giant  cells  (osteoclasts), 
with  the  deposit  of  fat  in  the  lacunae  {lacunar  resorption).  If  the 
bone  becomes  fragile  and  brittle,  there  is  said  to  be  osteopsathyrosis, 
or  fragilitas  ossium;  if  it  merely  becomes  light  and  porous,  without 
tendency  to  fracture,  the  condition  is  known  as  osteoporosis. 

Causes. — Causes  of  bone  atrophy  are  disuse  (as  in  amputation 
stumps,  paralyzed  limbs,  etc.);  chronic  disease,  especially  of  the 
nervous  system;  and  old  age.  In  most  cases  disuse  is  the  paramount 
cause.  Atrophy  from  pressure  is  also  seen,  as  in  tumors,  aneurysms, 
etc. 

Osteogenesis  Imperfecta. — Osteogenesis  imperfecta,  the  so-called 
"idiopathic  fragilitas  ossium,"  is  considered  a  definite  disease;  it 
is  congenital,  may  be  hereditary, -and  patients  seldom  reach  adult 
life.  Lovett  and  Nicholls  found  it  associated  with  changes  in  the 
adrenals  (1906).  Naturally  the  long  bones  of  the  limbs  are  those 
most  often  fractured,  usually  from  no  recognizable  injury;  union 
occurs  without  difficulty,  but  usually  with  deformity  owing  to  the 


DYSTliUl'lllES  OF  HONE  417 

frcciiK'iit  lack  of  splinting.     The  calvaria  may  remain  membranous 
throutrliout,  or  scattered  hone  islets  may  (IcNcIop. 


Fig.  423. — Extreme  bone  atrophy,  occurring  in  hereditary  syphilis,  in  a  girl,  aged 
eighteen  years,  who  had  not  walked  for  five  years.  The  continuity  of  the  tibia  is  lost, 
that  of  the  fibula  preserved  (concentric  atrophy).  The  tarsal  bones  and  articular 
extremities  of  the  tibia  and  fibula  show  eccentric  atrophy.     Episcopal  Hospital. 

Achondroplasia.  —  Achondroplasia  is  a  congenital  affection  in 
which  the  epiphyses  of  the  long  bones  become  ossified  abnormally 
early,  preventing  growth  of  these  bones  in  length,  and  giving  these 
patients  a  topical  appearance:  normal-sized  body,  with  dwarf-like 
extremities.  The  calvaria  (of  membranous  development)  usually  is 
unaffected.  Shattuck  classes  it  as  a  para-cretinous  condition,  and 
found  it  associated  with  changes  in  the  thyroid. 

Rachitis. — This  is  a  disease  apparently  dependent  on  malnutrition, 

and  having  its  chief  manifestations  in  the  osseous  system.    It  begins 

almost  exclusively   in  young  children    (under  three  years   of  age), 

but  seems  never  to  be  congenital.     The  patients  usually  are  not 

27 


418 


DISEASES  OF  BONE 


breast-fed,  but  have  been  brought  up  on  improper  milk  mixtures. 
The  osseous  changes  occur  chiefly  in  the  epiphyseal  cartilages,  and 
consist  in  irregular  over-growth  of  cartilage  cells;  some  of  these  car- 
tilaginous islets  may  be  displaced  into  the  metaphysis,  and  cause 
subsequent  trouble  (see  Multiple  Cartilaginous  Exostoses,  p.  443). 
Though  the  cartilage  cells  form  osteoid  tissue,  there  is  deficient  depo- 
sition of  lime  salts,  and  such  as  are  deposited  may  be  removed  by 
lacunar  resorption,  resulting  in  marked  osteoporosis.  When  the 
disease  passes  off,  after  lasting  from  three  to  five  years,  the  bone 
becomes  hard,  dense,  and  eburnated,  and  deformities  developed 
during  the  earlier  period  become  permanent. 

Symptoms. — Early  in  the  disease,  attention  may  be  drawn  to  the 
infant  on  account  of  constant  fretfulness,  sweating  about  the  head, 
backwardness  in  walking  or  even  crawling,  inability  to  sit  up  alone, 
delayed  dentition,  etc.  In  extreme  cases  the  limbs  are  very  painful, 
and  pseudo-paralysis  may  be  present.     When  ph\sical  signs  begin 

to  develop,  among  the  most  constant 
and  conspicuous  is  enlargement  of  the 
epiphyseal  cartilages  (Fig.  424),  ap- 
preciable especially  at  the  wrist,  ankle- 
and  costo-sternal  joints,  the  deformity 
in  the    last    named    situation   being 


P'iG.  424.  • —  Rachitis.  Age  five 
years.  Scarcely  able  to  walk  alone. 
Children's  Hospital. 


Fig.  425.  —  Rachitis.  Age  two  years. 
Showing  how  bow-legs  develop  from  persist- 
ent malposition.     Children's  Hospital. 


called  the  "rachitic  rosary."  The  head  appears  square,  the  forehead 
is  high,  and  the  fontanelles  remain  open  to  the  third  or  fourth  year. 
The  thorax  may  present  a  transverse  depression  (Harrison's  groove, 
1820)  from  the  constant  tug  of  the  diaphragm  on  the  softened  ribs. 
The  child  is  "pot  bellied,"  and  there  may  be  a  long,  rounded  kyphosis 
of  the  spine,  which  disappears  completely  on  hyperextension;  the  spine 


RACHITIS 


419 


is  iKnvluTc  rifijicl.  Various  (loformities  of  the  extremities  develoj),  due 
to  malposition  and  pressure  (Fi^-  425).  "  Kjioek-knee"  or  (jcnn,  vdhjiim 
usually  is  due  to  changes  in  the  lower  femoral  e])iphysis,  with  over- 
growth of  the  internal  condyle,  increasing  the  normal  outward  deviation 
of  the  leg;  "out-knee"  or  genu  varum  is  a  less  usual  deformity  than 
"l)ow-legs,"  in  which  the  main  deformity  is  in  tlie  leg  hones.  Knock- 
knee  and  how-leg  may  coexist  (Fig.  420),  generally  due  to  the  mother 
carrying  the  child  constantly  on  the  same 
arm  (that  side  on  which  knock-knee 
develops)  instead  of  alternating  on  the 
right  and  left.  Anterior  curvafure  of  the 
tibiw  is  a  conspicuous  deformity,  but 
very  slightly  disabling.  Rachitic  coxa 
vara  is  one  of  the  less  usual  deformities. 
Rachitic  (h'Jormity  of  the  iwlvis  may  in- 
terfere with  parturition. 

Treatment. — In  early  stages  constitu- 
tional treatment  is  most  important,  and 
may  be  successful  in  preventing  develop- 
ment of  deformities.  The  diet  must 
be  regulated,  and  as  soon  as  the  child 
can  be  weaned,  a  generous  mixed  diet, 
with  plenty  of  vegetables,  is  preferable 
to  continuance  with  milk;  of  all  tonics, 
exclusive  of  fresh  air,  cleanliness,  and 
sunlight,  which  of  course  must  be  pro- 
vided, none  is  so  good  as  cod  liver  oil; 
this  (not  an  emulsion,  but  the  pure 
Norwegian  oil)  may  be  given  three 
times  daily  in  doses  from  30  minims 
up  to  any  quantity  that  can  be  ab- 
sorbed. In  the  very  exceptional  cases 
in  which  this  is  not  tolerated,  the  syrup 
of  the  iodide  of  iron  may  be  substituted; 
and  in  many  cases  phosphates  should 
be  given  in  addition.  Locally,  begin- 
ning deformity  in  the  limbs  may  be  overcome  by  daily  gentle  manip- 
ulation in  the  mildest  cases;  or  by  splinting,  or  the  use  of  gypsum 
cases  renew'ed  every  few  weeks  with  the  legs  in  a  corrected  position. 
The  use  of  braces,  which  is  preferable  when  the  patient  can  afford 
to  purchase  them,  usually  will  overcome  slight  deformities  within 
eighteen  months  or  two  years,  if  applied  while  the  bones  are  still  soft 
(before  the  age  of  two  years  and  a  half).  Bow-legs  show  a  greater 
tendency  to  spontaneous  cure,  and  improve  much  more  rapidly  under 
treatment  by  braces  than  do  knock-knees.  Good  types  of  braces  are 
shown  in  the  accompanying  illustrations  (Figs.  427  and  428);  the 
modus  02)era7idi  of  braces  is  not  to  overcome  the  deformity  forcibly, 
but   to   prevent   growth  in  other  than  the  proper  direction;  they 


Fig.  426.  —  Rachitic  legs: 
knock-knee  on  right,  bow-leg  on 
left,  from  being  carried  con- 
stantly on  the  mother's  right  arm. 
Orthopaedic  Hospital. 


420 


DISEASES  OF  BONE 


require  constant  repair  and  readjustment,  and  the  surgeon  should  see 
that  they  are  in  repair  and  properly  adjusted  every  third  or  fourth 
week.     Usually  they  need  not  be  worn  at  ni^ht  in  bed. 

After  the  age  of  three  years,  and  occasionally  earlier,  very  little 
improvement  can  be  expected  from  conservatixe  measures,  and  an 
operation  should  l)e  undertaken.  Manual  correction  may  be  attempted 
by  Anzoletti's  method  (1909):  plaster  of  Paris  is  moulded  very 
accurately  to  the  extremity,  from  beyond  the  toes  well  up  to  the 
groin,  so  as  to  prevent  all  motion,  and  the  patient  is  kept  in  bed  on 
low  diet  for  four  or  five  weeks,  so  as  to  promote  bone  atrophy;  at 
the  end  of  this  time  the  gypsum  is  removed,  and  the  softened  bones 
sometimes  may  be  bent  in  the  hands  to  the  desired  shape  without 


Fig.  427. — Bow-leg  braces.  Pads  over 
internal  condyles  and  internal  malleoli, 
with  leather  apron  over  apex  of  de- 
formity.    Orthopaedic  Hospital. 


Fig.  428.  —  Knock-knee  braces.  Pads 
over  internal  condyles  and  internal  malleoli. 
Orthopaedic  Hospital. 


anesthetizing  the  patient.  Plaster  of  Paris  is  then  applied  in  an 
over-corrected  position,  and  the  patient  encouraged  to  walk  about, 
being  fed  up,  and  given  cod  liver  oil;  at  the  end  of  four  or  five  weeks 
the  bones  will  be  hard  enough  to  go  without  support.  I  have  tried 
the  method  several  times,  but  think  it  suitable  onl\'  for  acute  cases, 
especially  those  of  bow-legs;  in  cases  of  long  duration  it  is  better 
to  resort  to  osteoclasis  or  osteotomy.  Osteoclasis,  or  breaking  the 
bone,  is  accomplished  by  use  of  the  osteoclast  (Fig.  429),  the  patient 
being  anesthetized;  the  limb  is  then  put  \\\i  in  plaster  of  Paris  in 
over-corrected  position,  and  is  treated  as  a  fracture.  Osteotomy,  or 
division  of  the  bone  by  an  osteotome  (Fig.  451,4),  which  may  be 
described  as  a  chisel  bevelled  on  both  edges,  so  as  to  cut  straight 


RACHITIS 


421 


ahead,  is  i\ouv  tlir()U<!;li  a  minute  incision  wliicli  divides  the  j)eri- 
osteuni.  The  (»sti'(»t()ine  is  introchieed  throufih  the  periosteum,  is 
tur-iied  ti-ansNcrselx  to  the  loiii;'  axis  of  the  Hml>,  and  is  (hi\(ii  throu,<;li 


Fig.  42(». — Hopkins's  osteoclast.    Urthopii'flic  Hosi)ital. 

the  bone  by  a  mallet  in  such  a  way  as  to  divide  it  trans\ersely  all 
except  a  few  fibres  at  the  further  side;  several  cuts  in  the  bone  (all  at 
the  same  level)  may  be  necessary,  but  they  are  all  made  through  the 
one  skin  incision,  making  practically  a  subcutaneous  operation.      The 


Fig.  430. — Knock-knees,  osteotomy  of 
both  femurs.  (See  Fig.  431.)  Ortho- 
paedic Hospital. 


Fig.  431. — Result  of  osteotomy  of  femurs 
for  knock-knees.     Orthoptedic  Hospital. 


remaining  bone  fibres  are  then  fractured  by  hand,  the  incision  closed 
with  one  suture,  and  the  limb  is  put  up  in  plaster  of  Paris  in  an  over- 
corrected  position.    For  knock-knee  the  osteotomy  is  done  a  finger's 


422 


DISEASES  OF  BONE 


breadth  above  the  epiphyseal  Une  of  the  femur,  usually  on  the  outer 
side  of  the  bone  (Figs.  430  and  431);  for  bow-legs  it  is  done  at  the 


Fig.  432. — Bow-legs,  osteotomy  of 
both  tibiae.  (See  Fig.  433.)  Ortho- 
pjedic  Hospital. 


Fig.  433.— After  osteotomies  for  bow-legs. 
Orthopaedic  Hospital. 


apex  of  the  deformity,  usually  only  the  tibia  being  di\ided,  the  fibula 
bending  or  being  broken  by  hand  (Figs.  432  and  433).     The  correc- 


Fig.  434. — Anterior  curvature  of  tibite 
in  rachitis.  (See  Fig.  435.)  OrthopEedic 
Hospital. 


Fig.  435. — Anteriur  cur\ature  of  tibite 
after  osteotomy.     Orthopaedic   Hospital. 


tion  of  anterior  curvature  is  more  difficult  (Figs.  434  and  435).    The 
patient  is  not  allowed  to  walk  for  six  or  eight  weeks. 


OSTEITIS  DEFORMANS 


423 


Scurvy.  Scurvy,  which  may  compHcatc  rachitis  or  occur  lude- 
pcndcutly,  should' he  hornc  in  mind  as  a  possible  cause  of  symptoms 
of  bone  disease  in  infants.  Tenderness  of  shafts  of  long  hones,  with 
skiagraphic  evidences  of  subperiosteal  hemorrhages,  in  association 
with  other  scorbutic  symptoms,  should  make  one  suspicious  of  this 
condition.  The  diagnosis  from  tuberculous  or  subacute  septic  osteo- 
myelitis is  not  always  easy.  Constitutional  anti-scorbutic  treatment 
is   indicated. 


Fig  4.36  —Osteomalacia  (five  years'  duration)  in  a  patient,  aged  seventy-eight  years. 
Confined  to  bed  for  six  months.  Fracture  of  right  femur  occurred  the  day  before  the 
photograph  was  taken,  and  death  from  asthenia  two  days  later.  Dr.  F.  W  .  .Sinkler  s 
case.     Episcopal  Hospital. 

Osteomalacia.— Osteomalacia,  or  softening  of  the  bones,  is  an 
affection  occurring  mostly  in  women,  often  in  those  who  have  borne 
several  children  in  rapid  succession.  It  is  believed  to  be  associated 
with  ovarian  disease.  Scarcely  ever  does  it  occur  before  puberty. 
Deformity  is  progressive  and  marked,  involving  the  pelvis,  the 
vertebrarcolumn,  and  later  the  extremities.  "Spontaneous  fracture" 
(Fig.  43G)  may  occur,  but  is  not  frequent.  The  disease  has  been 
treated  by  oophorectomy,  but  some  surgeons  (Bastianelli)  claim  that 
the  benefit  from  such  operations  has  been  due  to  the  chloroform  inha- 
lation used  for  anesthesia;  and  they  now  induce  such  anesthesia 
without  doing  an  operation  (W.  J.  Mayo,  1910).  According  to  :Mayo, 
also,  different  Italian  observers  have  found  an  identical  and  specific 
diplococcus  in  the  periosteum  in  this  disease,  in  rachitis,  and  in  osteitis 
deformans;  when  a  culture  of  this  diplococcus  was  injected  into  rats 
it  produced  rachitis  in  the  very  young  animal,  and  osteomalacia  in 
adult  rats.     The  relation  of  thyroid  diseases  to  osteomalacia  is  not 

Osteitis  Deformans  {Paget' s  Disease  of  the  Bones,  1876)  occurs  in 
adult  life,  patients  usually  not  applying  for  treatment  until  well 
past  forty  years  of  age.  It  runs  a  very  chronic  course,  lasting  many 
years,  and"^  growing  progressively  worse,  though  intermissions  and 
exacerbations  may  occur.  It  is  characterized  in  its  earlier  stages 
by  osteoporosis,  causing  flexibility  and  deformity  of  the  bones;  but 
later  the  bones  hypertrophy  and  become  markedly  thickened.  Frac- 
ture is  rare.     The  lower  extremities  are  affected  earliest,  resulting 


424 


DISEASES  OF  BONE 


in  general  outward  and  anterior  bowing  of  the  knees  and  legs;  the 
spine  shows  a  long,  rounded  kyphosis,  and  the  calvaria  becomes  very 
much  thickened.  At  times  the  bones  are  very  painful,  but  often 
progressive  enlargement  of  the  head  is  what  first  calls  the  patient's 
attention  to  his  condition.     Eventually  loss  of  height  is  observed, 

the  attitude  resembling  that  of  anthropoid 
apes,  with  bowed  head,  disproportionately 
long  arms,  and  a  waddling  gait  (Fig.  437). 
Some  weakness  and  stiffness  usually  exist, 
but  death  occurs  only  from  intercurrent  dis- 
ease, usually  pulmonary,  or  from  advanced 
arteriosclerosis  which  is  a  prominent  feature 
of  the  malady. 

Treatment. — Treatment  is  chiefly  hygienic 
and  dietetic.  Thymus  or  thyroid  extract 
may  be  of  value.  Pain  may  be  relieved  by 
application  of  proper  orthopedic  apparatus. 
Hypertrophy  of  Bone. — This  may  be  com- 
pensatory, as  when  one  of  two  parallel  bones 
is  removed  for  disease,  the  other  may  become 
hypertrophied.  Or  it  may  be  the  result 
of  chronic  irritation,  as  in  thickening  of 
a  tibia  underlying  an  old  leg  ulcer.  In- 
crease in  thickness  and  weight  is  commoner 
than  increase  in  length,  though  the  latter 
occurs  to  a  marked  degree  in  some  ampu- 
tation stumps,  (p.  200) ;  sometimes,  too,  after 
fracture  or  tuberculous  or  inflammatory 
lesion  of  bone,  actual  increase  in  length 
may  occur,  or  at  least  the  affected  bone 
may  grow  faster  than  the  corresponding 
bone  on  the  other  side  of  the  body. 

Leontiasis  Ossea  (Virchow,  1865)  is  a 
disease  usually  arising  in  youth,  charac- 
terized by  hypertrophy  of  the  face  bones, 
giving  the  face  a  leonine  expression,  due 
to  the  gradual  obliteration  of  its  features. 
The  foramina  in  the  base  of  the  skull  may  be  narrowed,  causing 
exophthalmos,  blindness,  and  paralysis  of  the  various  cranial  nerves. 
Hypertrophy  of  the  calvaria  causes  pressure  on  the  brain,  with 
headaches,  convulsions,  etc.    No  treatment  is  of  avail. 

Acromegaly  (P.  ]Marie,  1886)  is  a  disease  of  youth  or  early  adult 
life,  characterized  by  hypertrophy,  enlargement  and  thickening  of 
the  apices  and  extremities  of  the  skeleton — fingers,  toes,  chin,  nose, 
etc.;  while  similar  soft  tissues  also  may  enlarge — lips,  tongue,  ears, 
and  even  penis  and  clitoris.  A  rounded  kyphos  develops  in  the 
dorsal  spine.  Headache  is  the  chief  subjective  s^■mptom.  The 
disease  often  is  caused  by  changes,  usually  neoplastic,  in  the  hypo- 


I'lG.  437. — Osteitis  defor- 
mans (Paget's  disease)  in  a 
patient,  aged  seventy-two 
years.  Duration  twelve 
years.  Orthopsedic  Hospital. 


INFECTIONS  OF  BONE 


425 


pliysis  (•(Tcl)ri;  n  skiagrapli  may  (lemonstratc  (Milargcincnt  of  the  sella 
tureica,  and  pressure  syini)tonis  from  hypophyseal  growth  may 
develop  later.  Treatment  by  pineal,  thyroid,  thymus,  or  other 
extracts  may  he  tried,  but  tlie  only  hoi)e  of  cure  consists  in  removal 
of  the  hypophysis  (see  p.  oS4). 


INFECTIONS  OF  BONE. 

Infection  of  a  bone  usually  occurs  through  the  blood-stream,  some 
locus  uiinori.s'  rcsLstcntia',  generally  due  to  injury,  determining  locali- 
zation of  the  infection.  Those  who  have  a  general  blood-infection 
(furunculosis,  typhoid  fever,  syphilis,  tuberculosis,  etc.),  therefore, 
are  predisposed  to  bone  infection.  Infection  of  bone  also  occurs 
in  compound  fractures,  but  as  in  these  the  products  of  inflammation 
are  readily  discharged  from  the  broken  surfaces  and  through  the 
wound  of  the  soft  parts,  the  disease  seldom  assumes  such  .serious 
proportions  as  when  infection  arises  in  the  unbroken  bone;  in  the 
latter  instance  the  very  structure  of  the  bone  prevents  swelling,  so 
that  strangulation  and  necrosis  occur  very  early. 

Acute  Periosteitis. — Acute  periosteitis  rarely  occurs  as  an  isolated 
affectioji;  in  almost  every  case  there  are  also  osteitis  and  osteomye- 
litis, and  it  is  probable  that  the  in- 
fection is  localized  first  in  the  medulla, 
and  is  propagated  to  the  periosteal 
surface  of  the  bone  through  the  Haver- 
sian canals.  In  convalescence  from 
typhoid  fever,  however,  subperiosteal 
abscess  may  occur,  and  in  most  such 
cases  there  is  no  appreciable  involve- 
ment of  the  medulla,  and  at  most 
only  a  superficial  caries  of  the  cortex. 
The  lesion  occurs  of tenest  in  the  long 
bones  and  the  ribs;  relief  of  symptoms 
(pain,  tenderness,  swelling,  fever,  etc.), 
and  rapid  cure  usually  follow  incision 
of  the  periosteum  and  scraping  the 
carious  bone  (Fig.  438). 

Chronic  Periosteitis. — Chronic  peri- 
osteitis is  a  frequent  lesion,  occurring 
in  many  of  the  dystrophies  already  de- 
scribed, or  as  the  result  of  contusions 
of  bone,  from  chronic  inflammation  of 
overlying  soft  tissues,  and  in  chronic 
infections,  especially  syphilis  (Fig. 
400).  The  long  bones  are  most  often 
affected:  the  periosteum  is  raised 
from  the  shaft  by  the  formation  of  new  bone,  and  the  resulting 
deformity  may  be  very  evident  on  inspection.     Distinct  periosteal 


Fig.  438.  —  Periosteitis  of  left 
tibia  nine  months  after  typhoid 
fever.  Age  nine  years.  Episcopal 
Hospital. 


426  DISEASES  OF  BONE 

nodes  may  form,  or  the  thickening  may  be  diffuse.  Usually  there  is 
a  good  deal  of  aching,  but  no  very  acute  pain;  the  osteoscopic  (bone- 
tiring)  pains  become  worse  after  exertion  and  when  the  warmth  of 
bed  induces  hyperemia  of  the  diseased  parts.  The  treatment  is 
much  the  same  as  for  syphilitic  periosteitis  (p.  442). 

Osteitis. — Osteitis  scarcely  ever  occurs  as  a  recognizable  affection 
apart  from  accompanying  osteomyelitis. 

Osteomyelitis. — This  is  an  acute  septic  infection  of  bone  marrow, 
usually  due  to  the  Staphylococcus  aureus,  and  affecting  mostly  the 
long  bones  of  the  extremities,  especially  the  tibia,  femur,  and  ulna, 
in  their  juxta-epiphyseal  portion,  which  is  named  by  Kocher  the 
metaphysis.  It  occurs  almost  exclusively  in  children  from  six  to 
sixteen  years  of  age,  and  often  follows  slight  trauma,  or  exposure 
to  cold  and  wet,  as  in  frequent  swimming  expeditions.  Predisposing 
causes  are  malnutrition,  convalescence  from  the  exanthemata  or  other 
general  infections. 

Owing  to  the  dense  bony  case  in  which  the  inflammation  occurs, 
it  is  extremely  rare  for  an  abscess  to  form;  instead  a  true  phlegmon 
of  bone  results,  infection  spreading  up  and  down  the  medulla.  The 
cortex  is  affected  secondarily,  and  in  most  cases  periosteitis  results 
from  transmission  of  infection  through  the  Haversian  and  \'olkmann's 
canals.  The  process  rarely  extends  into  the  joints,  even  in  adults, 
and  in  children  nearly  invariably  is  arrested  at  the  cartilage  of  the 
epiphyses.  Swelling  being  impossible,  the  medullary  tissues  become 
strangulated,  and  death  of  the  bone  in  large  masses  follows  (necrosis), 
its  extent  depending  on  the  destruction  of  the  marrow  cells  within, 
and  on  the  amount  of  separation  of  periosteum  on  the  surface.  Some- 
times the  entire  shaft  of  the  bone  becomes  necrotic,  is  spontaneously 
detached  at  its  epiphyses,  and  floats  in  pus  beneath  the  unruptured 
periosteum.  Usually,  however,  before  this  stage  is  reached  drainage 
is  instituted  by  operation,  or  the  periosteum  is  perforated  by  the 
pus  with  formation  of  a  parosteal  abscess  in  the  soft  tissues.  The 
periosteum  is  raised  from  the  cortex,  and  new  subperiosteal  bone  is 
formed;  this  at  first  is  plastic  but  later  becomes  sclerotic  and  is  known 
as  the  invulucrum;  and  such  portions  of  the  bone  marrow  as  survive 
form  new  bone  within,  so  that  eventually  the  necrotic  portion  of 
bone,  known  as  a  sequestrum,  is  more  or  less  completely  surrounded 
by  new-formed  bone  but  still  communicates  with  the  surface  through 
orifices  in  the  involucrum  known  as  cloacoB,  and  through  these  a 
discharge  of  pus  continues.  Several  sequestra  may  form,  each  having 
its  own  cloaca  or  cloacse,  and  discharging  on  the  skin  surface  through 
numerous  sinuses  (Fig.  439).  When  this  stage  of  the  disease  is 
reached,  it  assumes  a  chronic  form  usually  described  by  the  term 
Necrosis  (p.  431). 

Symptoms. — These  are  both  general  and  local,  the  former  often 
so  over-shadowing  the  latter  that  without  attenpon  to  the  history 
and  careful  physical  examination  the  disease  has  been  mistaken  for 
toxemia  resulting  from  typhoid  fever,  pneumonia,  meningitis,  etc. 


OSTEOMYELITIS 


427 


The  disease  may  be  usiiered  in  by  a  cliill,  with  sudden  rise  in  tempera- 
ture to  10;')°  F.  or  hi<^her,  the  child  appearing  very  ill  and  making 
little  complaint  of  the  extremity  afiectecl.  In  these  hyperacute  cases 
death  from  septicemia  may  occur  within  a  day  or  two  in  spite  of 
active  treatment.  In  most  cases,  however,  the  affected  limb  becomes 
painjul,  helpless,  and  swollen;  redness  may  not  be  evident.  Tender- 
ness is  extreme,  extending  throughout  the  shaft  of  the  affected  bone, 
but  most  intense  at  one  spot.    Indeed,  tenderness  usually  is  so  great 


N^.r'- 


^^ 


'■■:■! 


Fig.  439. — Diagram  of  changes  occurring  in  a  case  of  acute  osteomyelitis  of  the  tibia. 
In  the  first  figure,  there  is  diffuse  suppuration  in  the  medulla  of  the  diaphysis.  In 
the  second  figure,  the  products  of  inflammation  are  seen,  filling  the  space  between  the 
cortex  and  the  periosteum.  In  the  third  figure,  new  subperiosteal  bone  has  been  formed, 
and  within  this  involucrum  is  seen  a  large  sequestrum,  surrounded  by  pus,  which  dis- 
charges through  openings  in  the  involucrum,  known  as  cloaca.  In  the  fourth  figure, 
only  a  small  cortical  sequestrum  remains,  the  involucrum  has  become  very  dense,  and 
the  medullary  cavity  is  replaced  by  eburnated  bone,     (de  Quervain.) 


as  absolutely  to  prevent  palpation  at  the  seat  of  greatest  disease. 
Even  if  the  remainder  of  the  shaft  be  not  tender  to  palpation  or 
tappng,  prolonged  gentle  pressure  even  at  a  distance  will  eventually 
and  suddenly  become  acutely  painful;  this  is  a  valuable  diagnostic 
point  (Nichols,  1907).  The  disease  is  often  mistaken  for  acute  rheu- 
matic arthritis,  with  most  disastrous  results;  but  in  osteomyelitis  the 
joints  are  not  involved,  while  the  bones  are;  and  multiple  lesions, 
common  in  acute  rheumatic  fever,  are  rare  so  early  in  the  course  of 


428  DISEASES  OF  BONE 

osteomyelitis,  though  quite  frequent  hiter.  Tlie  distinction  between 
deep-seated  suppuration  of  bone,  and  serous  joint  efiusion  should 
not  be  diffieult  if  physical  examination  is  thorough.  The  mistake  is 
most  apt  to  occur  in  the  case  of  bones  which  are  not  subcutaneous 
(femur,  radius,  humerus),  but  ignorance  and  carelessness  may  err 
even  in  the  case  of  the  tibia  or  ulna.  At  later  stages,  if  the  patient 
survives,  edema  of  the  skin,  with  redness,  and  even  fluctuation, 
make  a  mistake  absolutely  unpardonable.  Throughout  the  course 
of  the  disease  the  surgeon  should  be  on  the  lookout  for  secondary 
invasion  of  other  bones,  which  is  often  overlooked  for  some  days, 
owing  to  a  subacute  onset. 


Fig.  440. — Skiagraph  of  acute  osteomyelitis  of  femur;  age  seven  years;  treated 
at  home  for  "typhoid  fever"  for  four  weeks.     Episcopal  Hospital. 

Treatment. — As  soon  as  the  diagnosis  is  made,  the  bone  should  be 
opened.  Delay  even  of  a  few  hours  is  dangerous  in  very  acute  cases, 
leading  to  widespread  necrosis,  pyemia,  and  multiple  secondary  foci  of 
osteomyelitis  in  other  bones.  In  a  case  of  which  I  have  cognizance, 
the  patient  was  treated  during  four  weeks  for  typhoid  fever,  with  the 
result  that  not  only  was  he  gravely  ill  for  many  months  with  pyemia, 
but  he  lost  his  entire  ulna,  and  developed  secondary  lesions  in  one 
tibia,  and  both  femora  (Fig.  440).  The  patient  should  be  anesthe- 
tized, the  limb  elevated  until  bloodless,  and  an  Esmarch  band  applied 
well  above  the  diseased  area;  a  free  incision  is  then  made  dividing 
the  periosteum  where  subcutaneous  or  after  exposure  through  the 
proper  intermuscular  space.  Usually  the  periosteum  is  found  more 
or  less  widely  detached  from  the  cortex  by  pus;  the  cortex  then  may 
look  white  and  dead,  but  generally  a  few  minute  bleeding-points 
(Volkmann's  canals)  may  be  seen.  If  the  periosteum  is  detached 
from  the  cortex  throughout,  and  the  shaft  is  loosened  at  its  epiphy- 
seal attachments,  the  entire  shaft  may  be  removed,  either  in  one 


OSTEOMYELITIS 


429 


piece,  or  l)y  wreiichiiig  each  ciul  free  after  sawiiiji;  the  h(jiie  across 
its  centre;  in  the  case  of  tlie  femur  and  liurnerus,  however,  where  no 
parallel  hone  exists  to  act  as  splint,  it  will  })e  better,  even  under 
these  circumstances,  to  leave  the  shaft  in  place  until  an  involucrum 
has  formed  dense  enough  to  maintain  the  form  of  the  limh.  Where 
the  i)eri()steum  is  only  partly  detached  from  the  hone,  or  where  the 
infection  has  not  yet  extended  from  the  marrow  out  through  the 
cortex,  the  cortical  bone  may  appear  normal;  but  in  all  cases  the 

surgeon  shonld  open  the  viedulla  to 
provide  drainage.  The  periosteum 
should  be  carefully  detached  from 
a  sufficient  area,  and  the  medulla 
exposed  by  trephine  or  g(^uge  and 
mallet.  The  marrow  usually  is  found 
softened,  grayish  yellow,  or  even 
purulent;  but  failure  to  find  frank 
pus  by  no  means  indicates  that  septic 
osteomyelitis  is  absent.  If  the  oper- 
ation is  done  sufficiently  early  the 
inflammation  may  not  have  progressed 
to  the  stage  of  suppuration;  and  in 
certain  cases  of  subacute  infection 
(perhaps  tuberculous),  there  is  what 
is  known  as  albuminous  osteomyelitis 
(Oilier,  1S72),  the  exudate  being  serous 
or  at  most  sero-purulent.  In  such 
cases,  or  if  the  diagnosis  is  doubtful. 


Fig.  441. — Specimen  of  tibia  ex- 
cised for  osteomyelitis;  below  is  seen 
the  trephine  opening  made  for  ex- 
ploration; above,  the  large  opening 
made  by  gouge  and  mallet.  Finally 
the  entire  diaphysis  was  excised. 
Episcopal  Hospital. 


Fig.  442. — Deformity  following  excision  of 
radius  twenty-five  j-ears  ago  for  osteomyelitis; 
useful  hand ;  man  works  as  laborer.  Episcopal 
Hospital. 


the  marrow  may  be  exposed  by  drill  holes.  If  the  medulla  is  found 
widely  infected,  a  second  button  of  bone  may  be  removed  at  a  dis- 
tance from  the  fir.st,  to  determine  the  extent  of  medullary  implication; 
and  the  intervening  bone  may  then  be  removed  by  gouge  and  mallet, 
cutting  a  long  gutter  in  the  cortex,  and  widely  exposing  the  medulla. 
It  never  is  proper  to  curette  the  marrow  or  attempt  its  removal  in 


430 


OSTEOMYELITIS 


any  way,  any  more  than  it  is  proper  to  curette  an  acute  phlegmon  of 
the  soft  parts  (p.  51);  it  is  probable  that  all  the  marrow  cells  are 
not  destroyed,  and  such  as  still  are  living  are  very  important  agents 
in  forming  new  cortical  bone.  The  periosteum  alone  is  not  always 
capable  of  forming  an  entire  new  shaft.  In  exceptional  cases  total 
resection  of  the  diaphysis,  even  if  this  is  not  wholly  necrotic,  may 
be  done    when   a   parallel   bone  exists  to  act  as  splint,  if  the  osteo- 


FiG.  443. — Deformitj-  from  excision  of  tibia  for  osteomyelitis.  Operation  two  years 
ago.  Xow  fourteen  years  old.  Ankylosis  of  knee.  Only  upper  and  lower  epiphyses  of 
tibia  remain,  with  about  three  inches  of  shaft  above  malleolus.  Gannot  stand  on  leg. 
Episcopal  Hospital. 

myelitis  is  so  widespread  as  to  render  probable  total  necrosis  later, 
or  if  the  patient's  condition  is  so  septic  that  prompt  convalescence 
is  demanded  (Fig.  441 ) ;  but  such  removal  often  leaves  a  deformed 
(Fig.  442)  or  helpless  limb  (Fig.  448),  which  later  may  require  an 
orthopedic  operation  (p.  504).  In  the  case  of  the  humerus  and  femur, 
where  the  disease  is  not  very  acute,  it  is  sufficient  to  trephine  the 
bone  at  the  limits  of  inflammation,  and  pass  a  drainage  tube  from 
one  opening  to  the  other  through  the  medulla.    If  guttering  has  been 


Fig.  444. — Granulating  wound  two  months  after  guttering  (evidement)  of  tibia 
for  osteomyelitis.     Children's  Hospital. 

done,  the  marrow  cavity  is  firmly  packed  with  iodoform  gauze,  the 
wound  is  left  widely  open,  and  is  allowed  to  heal  by  granulation  (Fig. 
444).  If  the  entire  diaphysis  has  been  removed,  the  same  course  may 
be  pursued,  or  the  periosteum  may  be  sutured  lightly  together, 
obliterating  the  cavity,  as  advised  by  Nichols  (1904). 

If  operation  has  been  done  early  enough,  necrosis  of  the  shaft  may 
not  occur,  and  permanent  healing  will  follow  the  primary  intervention. 


NECROSIS  OF  BONE 


431 


In  most  cases,  however,  portions  of  the  cortex  become  necrotic,  arc 
ext'oHated  as  seqnestra,  and  may  require  subsequent  operation  for 
their  i-cnio\al. 

Chronic  Osteomyelitis. — ^Tliis  is  rarer  tlian  tlie  acute  form  of  the  dis- 
ease and  is  due  to  a  less  virulent  infection.  The  bone  is  infiltrated 
witli  purulent  material,  its  lime-salts  are  more  or  less  al)sorbed  and 
the  narrow  cavity  obliterated.  Treatment. — Free  drainage  should  be 
j)rovided,  and,  if  possible,  all  the  dis- 
eased bone  should  be  gouged  away.  _  .i-1?'Jt 
Recurrences  are  frequent  unless  radical 
operation  is  done.  Eventually  hyper- 
trophy, sclerosis,  and  eburnation  occur. 

Necrosis. — Necrosis  is  the  term  ap- 
plied to  the  chronic  stage  which  succeeds 
acute  or  subacute  osteomyelitis.  It 
implies  the  presence  of  a  sequestrum, 
more  or  less  detached;  of  an  involvcrum, 
more  or  less  developed;  and  of  cloacce, 
usually  communicating  wuth  the  surface 
of  the  limb  by  sinuses  through  which 
bare  bone  may  be  felt.  Caries  is  that 
condition  of  bone  comparable  to  an  ulcer 
of  the  soft  parts,  there  being  no  actual 
sequestrum  (slough),  but  only  death  of 
bone  in  molecular  masses.  It  occurs 
chieflv    in    tuberculous    bone     disease 


V, 


W.W 


Fig.  445. — Cortical  sequestra  following  osteo- 
myelitis of  femur.     Episcopal  Hospital. 


FicJ.  446. — -Necrosis  of  hum- 
erus, showing  tubular  sequestrum, 
involucrum,  and  cloacse.  Os- 
teoporosis above.  Episcopal  Hos- 
pital. 


(p.  439).  A  sequestrum  may  be  due  to  necrosis  of  the  superficial 
cortical  layers  (Fig.  445),  or  there  may  be  a  total  or  "tubular"  seques- 
trum (Fig.  446)  The  superiosteal  bone  is  soft  and  plastic  when 
newly  formed,  and  possesses  great  powers  of  regeneration;  if,  how- 
ever, a  sequestrum  remains  beneath  it  long  enough,  the  involucrum 


432 


DISEASES  OF  BONE 


gradually  loses  its  regenerative  powers,  and  becomes  dense  and 
sclerosed;  sometimes  so  dense  that  the  finest  steel  makes  no  impres- 
sion on  it.     Therefore,  it  is  better,  whenever  possible,  to  remove 


I'"ir..  447. — Skiagraph  of  necrosis  of  til)ia,  showing  large  sequestrum  within 
involuoruni.     Ei>isco|>al  Hospital. 


Fig.  448. — Sequestrum  of  radius  ulcerating  out  eleven  months  after  compound 
comminuted  fracture.     Episcopal  Hospital. 

sequestra  while  the  involucrum  is  still  plastic,  so  that  the  cavity 
left  Avill  be  filled  up  promptly  by  periosteal  proliferation.  This  stage 
usually  ceases  about  two  or  three  months  after  the  primary  infection. 


M'J('lil)6l:S  OF  HONE 


433 


Tlio  jilastic  condition  of  tlu*  snhporiosteal  hone  may  he  (k'tcnnincd 

hy   sti{'kin<;'  a    noedk'  thr()n<i;h   it,   close  to  a   siiuis,   when   (•raekHn<; 

will    occur,    and    the    needle    will    he 

arreste«l  hy  the  necrotic  shaft  under- 
neath; or  it  may  he  ix)ssihle  to  see  the 

new-formed  hone  in  a  skiagraph  (Fif,'. 

447).     If  there  is  a  parallel  hone  pres- 
ent, as  in  the  forearm  and  leg,  removal 

of  the  sequestra  may  he  imdertaken  so 

soon  as  the  patient  convalesces  from 

tlu>  first  operation,  and  prompt  regen- 
eration e\en  of  an  entire  shaft  may 

he  anticipated;   but  when  the  femur 

or  humerus  is  affected,  it  is  better  to 

delay  secondary  operation  until  a  fairly 

strong  involucrum  has  formed.   This  is 

about  two  or  three  months  after  the 

onset  of  the  disease;    the  strength  of 

the  involucrum  may  he  determined  by 

skiagraphy,  and  its  total  thickness  should 

approximate  half  that  of  the  normal 

bone.     In   some  cases  sequestra  will 

work  themselves  loose,  and  eventually 

may  be  discharged  spontaneously  (Figs. 

448  and  449),   but  this  may  require 

many  years,  and  in  most  cases  ulti- 
mate   cure    is    much    accelerated    by 

operation. 

Sequestrotoniy,  as  the  operation  for 

the  removal  of  sequestra  is  called,  is 

done  under  Esmarch  anemia :  a  rubber 

bandage  is  applied  from  the  fingers  or  toes  to  above  the  upper  limit 

of  disease  (Fig.  4.30),  thus  removing  most  of  the  blood  from  the  limb; 

an  Esmarch  band  is 
then  applied  just  above 
the  termination  of  the 
elastic  bandage,  which 
is  then  removed,  leav- 
ing a  bloodless  field  for 
operation.  This  is  im- 
portant because  hem- 
orrhage from  the  in- 
volucrum and  medulla 
may  be  free,  and  unless 
the  wound  is  dry  it  is 
difficult  to  distinguish 

dead  from  living  bone.     The  limb  is  then  incised,  including  as  many 

sinuses  as  possible  in  the  line  of  incision,  or  excising  the  scar  of  previous 
28 


Fig.  449. — rhronic  osteomyelitis 
of  femur ;  age  forty-throe  years,  onset 
seven  years  ago.  No  symptoms  for 
several  years  until  a  few  weeks  ago, 
when  a  sequestrum  began  to  work 
loose;  sequestrum  extracted  through 
sinus,  which  promptly  healed.  Epis- 
copal Hospital. 


Fig.  450. — Rubber  bandage  applied  for  bloodless  opera- 
tion. The  Esmarch  band  is  then  applied  above  the  knee, 
and  the  rubber  bandage  is  removed  from  the  leg,  ex- 
posing the  seat  of  operation  (sequestrotoniy  of  tibia). 
Episcopal  Hospital. 


434 


DISEASES  OF  BONE 


operation.  If  the  subperiosteal  bone  is  still  plastic  it  is  incised  with  a 
heavy  knife  and  carefully  reflected  from  the  underlying  necrotic  shaft, 
whicii  is  then  removed  piecemeal  or  in  mass.  If  a  dense  involucrum  is 
present,  it  is  searched  for  cloacae,  and  the  location  of  sequestra  deter- 
mined, enough  of  the  overlying  bone  being  removed  to  permit  of  their 
removal ;  they  are  more  apt  to  be  completely  detached  from  surrounding 


Fig.  451. — Instruments  for  operation  on  bones:  1,  wooden  mallet;  2,  Hey's  saw;  3, 
chisel;  4,  osteotome;  5,  Volkmann's  sharp  spoon  or  bone  curette;  6,  Jones's  gouge;  7, 
gouge  bevelled  on  its  convexity;  8,  thumb  gouge;  9,  gouge  forceps;  10,  11,  sequestrum 
forceps;  12,  burr. 

healthy  bone  than  at  an  earlier  stage.  When  the  sequestrum  is  not 
completely  detached,  suspected  bone  should  be  removed  by  gouge 
and  mallet  until  healthy  bone  is  reached.  This  is  known  by  the 
fact  that  minute  blood  spots  on  the  bone  (Haversian  canals)  cannot 
be  washed  away  in  living  bone,  whereas  rinsing  a  chip  of  dead  bone 
in  water  will  remove  all  blood  from  its  surface. 

If  the  operation  is  done  before  sclerosis  of  the  involucrum  the  cavity. 


NECROSIS  OF  BONE 


435 


if  small,  may  hv  allowod  to  fill  with  blood-dot,  and  this  prohahly 
will  he  coiiviTtcd  into  hony  tissue  hy  suh-periosteal  proliferation 
(Fif^.  452).  When,  however,  the  iinoluerum  is  dense,  any  ea\ity  left 
will  remain  a  eavity,  unless  filled  with  some  substance  to  stiniulate 
ossification.     Probal)ly  the  best  substance  for  such  purposes  is  the 


Fig.  4.52. — Skiagraph  showing  involucrum 
of  ulna,  after  removal  of  sequestra.  Note 
numerous  cloacse.  Age  fourteen  years.  Epis- 
copal Hospital. 


Fig.  453.  —  Iodoform  boiie-wax  in 
cavity  of  tibia  (plombage) .  Episcopal 
Hospital. 


iodoform  bone  wax  of  Mosetig-Moorhof  (1903):  iodoform,  ()0  parts; 
spermaceti  and  oil  of  sesame,  each  40  parts.  This  is  heated  to  100°  C. 
while  being  mixed,  and  again  heated  to  50°  C.  before  being  poured 
into  the  bone  cavity.  Such  an  operation  is  termed  plombage  (Fig. 
453).     I  have  used  as  much  as  three  ounces  of  this  wax  at  one  time 


436 


DISEASES  OF  BONE 


(in  a  girl  of  seventeen  years),  but  others  have  reported  symptoms 
of  iodoform  poisoning  from  less  quantities.  The  best  results  follow 
when  the  cavity  is  dried  and  sterilized  by  a  hot  air  blast  before  pouring 
in  the  wax;  or  by  the  actual  cautery,  taking  care  only  to  sear  and 
not  to  char  the  bone.  If  this  cannot  be  done,  the  cavity  may  be 
swabbed  out  with  strong  antiseptics  and  dried  with  sterile  gauze. 
In  these  chronic  cases  there  is  only  an  attenuated  infection.  The 
soft  tissues  are  sutured  tight  over  the  wax  as  it  cools,  no  drainage 
being  employed;  and  though  some  of  the  wax  may  be  discharged 
eventually  through  a  sinus,  convalescence  is  much  less  tedious  than 
if  no  bone  filling  had  been  employed.  Beck's  bismuth  paste  (p.  484) 
may  be  employed  in  small  quantities  instead  of  iodoform  bone  wax, 
but  is  less  suitable.  In  cases  where  the  cavity  left  is  exceedingly 
large,  it  is  better  to  resort  to  the  old  operation  of  evidenient,  in  which 
the  entire  anterior  and  most  of  the  lateral  walls  of  the  involucrum 


Fig.  454. — Acute  epiphysitis  of  left  humerus, 
upper  end ;  age  eight  months.  Admitted  with  diag- 
nosis of  scurvy.  Temperature  rose  to  105°  F., 
and  at  operation  epiphysis  was  found  separated. 
Recovery.     Children's  Hospital. 


Fio.  455. — Diagram  showing 
the  relation  of  the  upper  epiphysis 
of  the  humerus  to  the  shoulder- 
joint. 


are  removed  by  gouge  and  mallet,  so  that  only  a  superficial  trough 
remains  representing  the  posterior  wall  of  the  involucrum,  thus 
allowing  the  soft  parts  to  grow  down  and  across  the  cavity  (Fig.  444), 
which  is  packed  with  gauze.  Though  healing  may  take  a  year  or 
more,  the  cure  eventually  is  complete.  Neuber  (1890)  tried  to  hasten 
recovery  by  nailing  flaps  of  soft  tissues  in  the  gutter  left  by  cvideinent. 
Acute  Epiphysitis. — While  in  children  osteomyelitis  is  apt  to  begin 
and  to  manifest  its  greatest  intensity  in  the  metaphysis,  in  infants 
it  occurs  almost  exclusively  in  the  epiphysis  (Fig.  454),  and  owing 
to  certain  special  features  requires  separate  mention.  The  condition 
frequently  is  overlooked,  from  neglect  of  physical  examination;  and 
the  closeness  of  a  lesion  to  a  joint  (the  shoulder  and  hip  are  especially 
liable  to  the  disease)  may  render  it  likely  to  be  confused  with  acute 
rheumatic  arthritis  or  joint-injury;  indeed,  as  the  epiphysis  becomes 
detached  from  the  shaft  quite  early  in  the  disease,  the  resemblance  to 
fracture  is  considerable.    Infection  of  the  joint  is  frequent,  owing  to 


TUBEliCl'LOSrS  OF  HOSE  437 

tlie  i)()siti()ii  of  the  cjiipliyseal  line  which  even  at  the  shoulder  is 
l)artly  iiitra-articiihir  (Fig.  4"),")),  thus  alVordiufj;  scarcely  any  chance 
for  extra-articular  drainage. 

Treatment.^Treatment  consists  in  early  incision,  exposing  the 
sei)tic  focus  with  curette,  and  draining  the  cavity  with  gauze.  If 
pyarthrosis  develops,  the  joint  also  should  be  drained.  Deformity 
from  interference  with  growth,  flail-joint,  or  i)athological  luxation 
(especially  at  the  hip)  may  follow.     Ankylosis  is  rare. 

Bone  Abscess.— As  a  result  of  osteomyelitis  a  residual  abscess 
(]).  SO,"))  may  form  in  bone,  most  frequently  in  the  tibia  {Brodies 
abscess,  1S24).  \Vry  rarely  such  an  abscess  may  be  the  j^rimary 
lesion,  no  diffuse  osteomyelitis  having  preceded  it;  such  cases  usually 
are  tuberculous.  A  bone  abscess  is  confined  by  a  dense  wall  of 
sclerosed  bone,  and  may  remain  latent  for  many  years,  causing 
intermittent  attacks  of  pain  and  limping,  and  being  finally  roused 
to  acute  stage  by  trauma  or  constitutional  affection. 

Diagnosis.— Tlie  diagnosis  depends  on  the  history,  persistent  local- 
ized bone  tenderness,  and  .v-ray  examination. 

Treatment.— The  dense  wall  should  be  cut  away,  the  pus  evacuated, 
the  cavity  sterilized,  and  treated  as  other  bone  cavities  (p.  435).  If 
the  abscess  is  small,  and  if  its  outlines  can  be  well  defined  by  .r-ray 
examination,  it  may  be  possible  to  excise  it  in  one  mass,  by  cutting 
through  healthy  bone  on  all  sides. 

Fibrous  Osteitis.— By  this  term  is  understood  a  condition  regarded 
by  all  more  recent  investigators  as  an  inflammatory  disease  of  bone 
"in  which  the  medullary  tissue  is  replaced  by  a  new  formation  of  con- 
nective tissue  with  or  without  cyst  formation."  (Bloodgood,  1910.) 
Its  relations  to  bone  cysts  and  myeloma  (p.  445)  are  not  well  defined. 
It  occurs  in  children,  affects  oftenest  the  humerus,  femur,  and  tibia, 
and  begins  insidiously;  in  very  many  cases  spontaneous  fracture 
or  the  deformity  resulting  from  such  an  unrecognized  fracture  is 
what  first  calls  attention  to  the  condition.  There  may  be  pain  and 
increase  in  the  size  of  the  bone,  but  the  disease  usually  is  easily  dis- 
tinguished from  malignant  neoplasms  of  bone  by  the  long  duration 
of  symptoms.  Unless  the  patient  is  seen  for  fracture,  the  swelling 
and  pain,  neither  very  marked,  usually  exists  for  a  year  or  niore 
before  the  surgeon  is  consulted.  Diagnosis  is  much  aided  by  the 
.r-ray,  which  wall  exclude  sarcomatous  change,  and  may  show  cyst 
formation. 

Treatment.— The  treatment  consists  in  removal  of  all  diseased 
tissue  h\  gouge  or  curette,  the  ca^'ity  being  treated  as  one  following 
seq  nest  rot  omy. 

Tuberculosis  of  Bone.— Tuberculosis  rarely  affects  the  diaphyses 
of  long  bones,  its  lesions  being  confined  almost  exclusively  to  the 
region  of  the  epiphyseal  cartilages;  but  in  short  bones  (hands,  feet, 
vertebra?),  diffuse  medullary  involvement  is  common.  There  are 
good  anatomical  reasons  for  this.  As  noted  in  Chapter  III,  tubercle 
bacilli  usually  find  lodgement  in  the  lymph  nodes,  and  only  when 


438  DISEASES  OF  BONE 

these  caseate  and  rupture  do  the  })acilli  escape  into  the  })lood-streain. 
Infection  of  bone,  therefore,  occurs  through  the  blood,  the  lesion 
being  an  infarct  or  embolus  which  has  successfully  passed  through 
the  pulmonary  capillaries.  There  are  three  sets  of  arteries  supplying 
long  bones — one,  the  main  nutrient  artery,  enters  the  diaphysis, 
and  branches  in  both  directions;  a  second  enters  the  metaphysis, 
while  the  epiphyseal  arteries  form  the  third  group;  now  all  these 
arteries  send  their  terminal  branches  to  the  region  of  the  epiphyseal 
cartilage  (which  is  bloodless),  and  they  do  not  inosculate  with  each 
other.  It  is  in  this  region,  therefore,  that  bacterial  emboli  lodge, 
no  matter  by  which  of  the  three  arterial  systems  they  enter  the 
bone.  In  short  bones,  however,  the  main  nutrient  artery  breaks 
up  into  small  branches  almost  as  soon  as  it  enters  the  cortex,  and 
tuberculous  emboli  are  arrested  in  the  medulla.  It  is  denied  by  some 
that  trauma,  in  creating  a  locus  mi  nor  is  resisi  entice,  has  any  influence 
in  determining  the  localization  of  tuberculous  foci  in  bone;  but  clinic- 
ally it  is  a  well  established  fact  that  any  site  of  lessened  resistance 
is  prone  to  invasion  by  tuberculosis,  whether  the  primary  change  is 
traumatic  or  infectious.  According  to  Ely  (1911)  the  reason  that 
tuberculosis  develops  in  the  neighborhood  of  the  epiphyses,  and  not 
in  other  regions  (as  the  brain)  which  are  supplied  by  end-arteries,  is 
because  in  the  epiphyses  the  soil  is  suitable  for  the  growth  of  tubercle 
bacilli,  while  elsewhere  it  is  not  (see  p.  476).  If  the  tuberculous 
process  begins  on  the  shaft  side  of  the  epiphyseal  cartilage  of  a  long 
bone  (i.  e.,  in  the  metaphysis),  the  resulting  lesion  resembles  a  very 
subacute  type  of  septic  osteomyelitis;  this  condition  appears  to  be 
more  common  in  Great  Britain  and  on  the  continent  of  F.urope  than 
in  this  country.  Its  existence  was  recognized  by  Volkmann  in  1S79, 
and  Stiles  has  recently  (1912)  called  renewed  attention  to  it.  If, 
however,  the  tuberculous  embolus  lodges  on  the  joint  side  of  the 
epiphyseal  cartilage  the  joint  is  quickly  invaded ;  and  this  often  occurs 
even  when  the  metaphysis  is  first  involved,  especially'  in  joints  where 
the  epiphyseal  cartilage  is  largely  inside  the  joint  capsule. 

The  affected  area  undergoes  caseation,  the  bony  framework  melting 
away  in  the  centre,  while  proliferation  may  take  place  under  the 
periosteum.  In  favorable  cases  the  disease  may  become  latent, 
by  encapsulation  of  the  tuberculous  focus;  or  softening  may  extend, 
the  cold  abscess  may  rupture  into  a  neighboring  joint  (very  frequent 
in  case  of  long  bones),  may  work  its  way  to  the  skin  surface  through 
a  sinuous  tract,  or  may  cause  gradual  expansion  of  the  cortex,  with- 
out rupture  (especially  in  the  phalanges).  Secondary  pyogenic 
infection  may  occur,  especially  after  sinus  formation,  and  an  osteo- 
myelitis originally  purely  pyogenic  may  become  secondarily  infected 
by  tuberculosis.  For  such  cases  more  or  less  formal  operation  (seques- 
trotomy,  plombage,  evidement),  may  be  required.  Joint  infection 
is  so  very  frequent  in  the  case  of  long  bones  (especially  the  femiir, 
tibia,  and  humerus)  that  it  is  best  to  study  epiphyseal  tuberculosis 
in  connection  with  tuberculosis  of  joints  (p.  476).     This  is  also  the 


TUUERCVLOSHS  OF   HOSE 


439 


case  ill  tlio  hoiios  of  the  carpus  and  tarsus.     \'crtcl)ral  tuberculosis 
is  considered  in  Chapter  XVI II. 

In  tlie  metacarpal  bones  and  piialauges  a  diffuse  tuberculous 
osteomyelitis  follows  the  arrest  of  tuberculous  emboli,  and  the  lesions 
are  the  same  in  kind  as,  though  running 
a  nuich  less  acute  course  than  in  pyo- 
genic osteomyelitis.  Tuberculous  dactyl- 
itis, as  this  form  is  called,  occurs  almost 
exclusively  in  infauts  and  young  children 
(P'igs.  37  and  45(3) ;  it  may  affect  several 
digits,  and  may  be  accompanied  by 
tuberculous  bone  disease  elsewhere. 
Caries  of  facial  bones  in  infants  usually 
is  tuberculous.  Local  rest  and  clean- 
liness, and  general  hygienic  measures 
usually  cure  the-  disease,  though  the 
finger  maj'  be  deformed  from  extrusion 
of  sequestra,  ankylosis,  etc. 

Caries  of  the  sJxull  from   tuberculosis   is  not  very  rare  in  adults 
(Fig.  457).     The  diagnosis  depends  on  the  discovery  of  tuberculosis 


Fig.  45G. — Tuljorculous  dactjl- 
itis,  early  stage;  age  three  years; 
duration  seven  months.  Epis- 
copal Hospital. 


Fig.  457. — Tuberculous  caries  of  skull.  Age  thirty-nine  years.  Phthisis  for  eight 
or  nine  years.  Present  trouble  began  by  swelling  like  wen,  nine  months  ago.  Six 
months  ago  this  ruptured  and  has  been  moist  or  scabbed  even  since.  Depression  in 
bone  palpable.  Has  another  area  still  in  wen  stage,  fluctuating  and  red.  Episcopal 
Hospital. 

elsewhere  in  the  body  (notably  the  lung),  on  the  exclusion  of  syphilis, 
and  on  the  chronic  and  indolent  course  of  the  affection. 


440 


DISEASES  OF  BONE 


Syphilis  of  Bone. — Osseous  manifestations  of  syphilis  occur  late 
in  the  disease,  with  the  exception  of  fugacious  attacks  of  periosteitis 


llBllBiUi''^^^ 

m 

M 

^^^^^^^^^HH^^^ 

^^t^ 

Fig.  458. — Syphilitic  dactylitis.  Age  twenty-eight  jears;  duration  five  months. 
Five  years  after  chancre.  Pathological  fracture  of  jthalanx.  (See  Fig.  459.)  Episcopal 
Hospital. 


Fig.  459. — Skiagraph  of  finger  shown  in  Fig  458.     (Syphilitic  dactylitis.)     Note 
pathological  fracture  of  phalanx.     Episcopal  Hospital. 


SYPIIILTS  OF   HONE 


441 


in  tlic  socoiulary  stajje.  'V\w  losioiis  roscmhk'  tliose  oc-curring  in  the 
other  infectious  granulomas,  involving  softening  and  caries,  or  pro- 
lilcration  and  ehurnation.  Both  processes  frcfjuently  occur  at  once 
in  (lill'crt'iit   j)arts  of  the  same  l)<)ne. 

In  licralltdri/  .sj/phllis  the  earliest  bone-lesions  are  those  in  the 
cranium  and  phalanges,  occurring  mostly  in  young  in'ants.  In 
the  cranium  softening,  caries,  and  su])puration  are  fre(iuent,  with 
circumferential  jxTiosteal  o\er-growth,  forming  the  so-called  Parrot's 
nodes  (1S79);  or  mere  thinning  of  the  skull  from  malnutrition  and 
pressure  may  occur,  affecting  especially  the  occipital  bone.      Caries 

of  the  bony  nasal  septum  and 

l)alate  bones  also  is  seen. 
Si/plilliilc  daciiilitis  is  difficult 
to  distinguish  from  tuberculous 
dactvlitis,  but  usuallv  mav  be 


Fig.  460. —  Sj-philitic  perio.stcitis  of  left 
tibia,  early  stage;  duration  three  months. 
Hereditary  syphilis,  patient  also  having 
Hutchinson  teeth  and  interstitial  kera- 
titis and  marked  genu  valgum.  Age  thir- 
teen years.  (See  also  Figs.  461,  462,  and 
463.)     Orthopaedic  Hospital. 


Fig.  461. — Same  patient  as  Fig.  460: 
Sabre-blade  tibia  (left),  from  photo- 
graph two  years  after  Fig.  460.  Note 
also  syphilitic  arthritis  of  right  knee. 
Orthopaedic  Hospital. 


recognized  by  the  family  history,  existence  of  specific  lesions  else- 
where, and  results  of  anti-syphilitic  remedies;  it  occurs  in  acquired 
as  well  as  in  congenital  syphilis  (Figs.  458  and  459).  In  tuberculous 
dactylitis  microscopical  examination  or  inoculation  may  reveal  the 
nature  of  the  process.  Constitutional  anti-syphilitic  treatment  of 
the  mother,  if  the  infant  is  nursing,  always  should  be  employed  in 
connection  with  local  treatment. 

From  one  to  six  years  of  age  there  are  few  manifestations  of  heredi- 
tary syphilis,  but  after  this  period  di.sease  of  the  long  bones  is 
frequent,  especially  of  the  tibise,  one  or  both  of  which  develop  a 
periosteitis,  at  first  more  or  less  well  defined  (Fig.  400),  but   later 


442 


DISEASES  OF  BONE 


diffuse  and  produeino;  characteristic  "  sabre-})lade  deformity"  (Fig. 
461).  The  bone  may  be  softened  early  in  tlie  aft'ection,  but  later 
thickening  and  elongation  occur,  and  the  bone  is  markedly  sclerosed 
(Figs.  402  and  4()3).  If  the  pain  does  not  yield  to  anti-syphilitic 
remedies,  the  bone  may  be  drilled  in  various  places,  thus  relieving 
tension;  while  during  the  stage  of  osteoporosis  much  comfort  may 
be  derived  from  support  by  braces.      The  deformity  is    incural)le. 


Fig.  462 


Fig.  463 


Figs.  4G2  and  46.3. — Skiugraphs  of  syphilitic  periosteitis  of  tibiae,  showing  "sabre- 
blade"  deformity  with  hypertrophy  and  sclerosis  of  the  bones.  Age  nine  years. 
Epi-scopal  Ho.sipital. 

Osteomyelitis  rarely  is  due  to  syphilis,  but  in  children  gummatous 
epiphyseal  lesions  may  occur,  and  cause  marked  local  over-growth 
(Post,  quoted  by  Nichols,  1907);  or  by  softening  and  invasion  of  the 
joint  may  produce  tuberculous-like  arthritis  (p.  503). 

In  acquired  syphilis  the  chief  bony  manifestation  of  the  disease  is 
the  periosteal  gumma,  which  may  begin  with  pseudo-inflammatory 
symptoms,  and  occasionally  breaks  externally;  under  proper  anti- 
syphilitic  treatment,  however,  it  is  apt  to  be  absorbed,  leaving  a 
depressed  area  on  the  surface  of  the  bone  (calvaria,  nasal  bones, 
palate,  sternum,  tibia)  due  to  dry  caries  and    lacunar    resorption, 


rVMORS  OF   liOXE 


443 


witli  a  tlii(k(Mi(>(l  niar<;;in  due  to  periosteal 
prolitVratioii.  It"  the  process  is  arrestetl  l)e- 
fore  softening  of  tlie  gumma  occurs,  perios- 
teal nodes  or  exostoses  may  remain  instead 
of  dei)ressi()n  due  to  caries.  Rarely"  a  dis- 
tinct sequestrum  forms;  this  is  characteris- 
tically worm-eaten  in  appearance  and  may 
require  many  years  for  exfoliation.  In  all 
cases  where  sinus  formation  occurs,  sec- 
ondary pyogenic  infection  is  frequent,  and 
sequestrotomy,  etc.,  may  be  necessary;  in 
other  cases  constitutional  treatment  alone 
often  is  sufficient  to  relieve  symptoms  and 
arrest  the  progress  of  the  disease.  Pain- 
ful exostoses  may  be  removed,  or  eburnated 
bone  (Fig.  464)  drilled. 

TUMORS  OF  BONE. 


Fig.  464. — .Syphilitic  osteitis 
causing  eburnation  of  the  tarsal 
bones.  Patient  had  a  chancre 
eighteen  years  ago,  and  has 
pulmonary  emphysema  which 
may  possibly  be  an  etiological 
factor  in  the  bone  disease. 


Here  may  be  recognized  diseases  which 
comprise  what   Adami  calls  blastomatoid 

conditions   (p.    107),   as  well    as   true   neoplasms  of  bone.     In  the 
former  category  belong,  perhaps,   certain   of  the  diseases  described 

as  dystrophies   of   bone,  as   well  as  many 
forms  of  exostosis,  hyperostosis,  etc. 

Among  the  exostoses  (p.  112)  several 
clinical  types  are  recognizable,  and  deserve 
short  mention  here.  They  are  divided 
into  the  cartilaginous  and  fibrous  forms. 
Cartilaginous  exostoses  are  single  or  multiple 
out-growths  arising  from  epiphyseal  cartil- 
ages or  in  the  neighborhood  of  epiphyseal 
lines;  they  are  most  frequent  at  the  upper 
end  of  the  tibia  (Fig.  465)  or  lower  end  of 
the  femur  (Fig.  466),  and  may  cause  trouble 
by  pressure  on  structures  in  the  popliteal 
space.  Excision  is  the  proper  treatment, 
removing  also  the  portion  of  bone  from 
which  they  grow,  as  recurrence  is  frequent. 
One  typical  aflFection,  usually  described  by 
the  term  Multiple  Cartilaginous  Exostoses 
(Fig.  467),  is  thought  by  some  to  be  a 
distinct  disease;  but  it  seems  probable  that 
it  may  follow  any  form  of  chronic  inflam- 
mation, infectious  or  toxic,  whose  lesions 
are  located  in  the  bones,  and  it  is  certain 
that  it  may  be  associated  with,  if  not  caused 
by,  rachitis  or  syphilis,  may  affect  several 


Fig.  465.  —  Cartilaginous 
exostosis  of  outer  tuberosity 
of  left  tibia  growing  into  pop- 
liteal space.  Begun  at  age  of 
sixteen  years,  and  was  re- 
moved three  years  later.  Re- 
currence noted  first  five  weeks 
ago. 


444 


DISEASES  OF  BONE 


in  the  same  family, 
1903).  It  appears 
seen  one  case  in  an 
patient's  attention 
especially  the  long 
epiphyseal  lines  (p 
pressure.     If   this 


and  extend  through  se^•eral  generations  fLippert, 
usually  about. the  age  of  pubert}',  though  I  have 
infant;  and  it  may  exist  for  some  years  before  the 
is  attracted  by  the  out-growths.  These  affect 
bones  of  the  extremities,  occur  mostly  at  or  near 
.  110),  and  seldom  cause  symptoms  except  rom 
exists   the  offending  exostoses  mav  be  remo\ed. 


Fig.  466. — Skiagraph  of  exostosis  of  femur  spring- 
ing from  region  of  epiphysis  and  growing  toward 
diaphysis.  Girl,  aged  sixteen  years.  Duration  two 
years.  Began  three  months  after  injury  from  runner 
of  sled.    Orthopaedic  Hospital. 


Fig.  467. — Multiple  cartil- 
aginous exostoses,  in  a  negro 
girl,  aged  thirteen  years. 
Children's  Hospital. 


Patients  sometimes  claim  that  a  certain  exostosis  has  appeared  more 
or  less  suddenly,  or  that  another  has  decreased  in  size.  Disturb- 
ances of  gr(n\-th,  distortions,  subluxations,  etc.,  are  frequent  in  the 
long  bones  CBessel-Hagen,  1891).  Fibrous  exostoses  arise  either  from 
periosteum  or  its  attached  fascia  or  tendons.  Several  clinical  types 
are  well  known,  including  the  ivory-like  exostosis  of  the  skull  (men- 
tioned at  p.  112);  subungual  exostosis,  found  almost  solely  on  the 
great  toe;  exostoses  of  the  facial  bones,  especially  the  nasal  process  of 
the  maxilla  (leontiasis  ossea  may  commence  thus),  and  the  mandible; 


TUMOh'S  OF  HOSE 


445 


and  exostoses  in  connection  with  tendinou.s  infirrti(>n.<i  (see  myositis 
ossificans  traumatica,  j).  274),  where  a  hursa  may  develop  {exoatosia 
hnrmta)  in  wliich  cartihiginous  l)odies  may  float. 

FihrotiKis,  arising  From  ixTiosteum,  are  rare;  tliey  form  one  \ariety 
of  ])()ly|)i  in  the  naso])haryn\,  and  on  the  jaw  constitute  the  "fibrous 
epulis." 

Choiidrotitas  and  O.stcoiiKi.s  iuuc  heen  sufHciently  described  in 
Chapter  W. 


Fig.  468. — Bone  cyst  of  humerus,  duration  fifteen  months;  recent  fracture  from  slight 
injury.  Cured  by  evacuation  and  scraping;  and  crushing  in  the  thin  wall  of  the  cyst 
to  obliterate  the  cavity.    Episcopal  Hospital. 


Bone  Cysts. — These  have  been  carefully  studied  by  Bloodgood 
(1910),  who  collected  89  cases;  09  of  these  had  s(mie  relation  to  osteitis 
fibrosa  (p.  437).  The  cyst  usually  is  single,  and  contains  thin,  dark 
brown  fluid,  never  distinctly  hemorrhagic,  and  never  under  great 
tension;  there  usually  is  a  distinct  fibrous  lining  inside  the  bony 
shell,  and  even  when  this  is  absent,  evidences  of  fibrous  osteitis  can  be 
found  microscopically.  Unless  the  cysts  are  huge  and  of  very  long 
duration,  or  there  has  been  a  pathological  fracture  (Fig.  408)  there  is  no 
alteration  in  the  overlying  periosteum.    Small  islets  of  cartilage  may 


44G  DISEASES  OF  BONE 

exist  in  the  cyst  wall,  and  a  few  giant  cells  may  be  present;  but  neither 
occurs  in  sufficient  amount  to  render  likely  confusion  with  degener- 
ated chondromas  or  with  myelomas.  The  symptoms  for  which  these 
patients  seek  relief,  as  well  as  the  proper  treatment,  have  been  given 
in  connection  with  fibrous  osteitis  (p.  437).  The  diagnosis  from 
other  forms  of  cyst  (degenerated  chondromas,  echinococcus  disease, 
etc.),  which  are  rare,  is  not  very  important  clinically,  as  the  same 
treatment  is  required.  In  hone  abscess  there  usually  is  a  history  of 
previous  osteomyelitis,  and  the  .r-ray  shows  the  abscess  surrounded 
by  sclerosed  bone.  From  myeloma,  except  in  cases  of  very  short 
duration,  distinction  usually  may  be  made  by  .r-ray;  myeloma 
expands  the  bone  rather  abruptly,  may  cause  periosteal  prolifer- 
ation, does  not  extend  far  up  or  down  the  medullary  cavity,  some- 
times shows  trabeculse,  and  has  no  fibrous  lining  beneath  the  cortex; 
the  benign  bone  cyst  causes  little  expansion  of  bone,  extends  for 
some  distance  up  and  down  the  medulla,  and  usually  a  faint,  fibrous 
lining  can  be  detected.  ^Myeloma  occurs  in  young  adults  past  twenty 
years  of  age;  and  spontaneous  fracture  is  rare.  Bone  cysts  occur 
mostly  in  children,  and  spontaneous  fracture  is  frequent.  Suh- 
yeriosteal  hematoma  may  resemble  a  bone  cyst  if  encapsulated  by 
new-formed  sub-periosteal  bone.  The  cortex  may  be  slightly  eroded, 
but  the  medulla  never  is  involved.  Such  cysts  are  not  uncommon 
in  the  cranial  bones  of  infants,  from  obstetrical  injury,  but  may  arise 
elsewhere  from  contusion  of  bone. 

Giant-celled  Myeloma. — This  tumor  is  described  at  p.  113;  its 
differential  diagnosis  from  benign  cyst  has  just  been  discussed. 

Bone  Aneurysms,  so-called,  usually  are  of  the  type  of  faUe  osteoid 
aneurysm  mentioned  at  p.  113.  Usually  they  are  medullary  sarcomas 
of  highly  malignant  type  (spindle-  or  even  round-celled),  but  they 
may  arise  from  a  giant-celled  myeloma.  They  are  distinguished  from 
benign  bone  cysts  by  the  frankly  hemorrhagic  nature  of  their  con- 
tents, which  are  under  pressure;  by  much  more  rapid  growth,  early 
perforation  of  the  cortex  and  invasion  of  the  soft  tissues;  and  when 
this  stage  has  been  reached,  by  expansile  pulsation,  sometimes  accom- 
panied by  bruit.  Giant-celled  myeloma  rarely  presents  any  cystic 
centre,  and  if  one  exists  it  is  relatively  small,  and  surrounded  by 
typical  myelomatous  tissue;  whereas  in  the  pulsating  sarcomas  of 
bone,  the  blood-cyst  comprises  the  main  tumor,  and  the  sarcoma  cells 
exist  in  a  thinned-out  layer  around  the  periphery. 

Treatment. — The  treatment  is  prompt  disarticulation  above  the 
affected  bone.  Local  recurrence  or  internal  metastases  usually  occur 
in  a  few  months,  and  death  follows  within  a  year. 

Sarcoma. — Bone  is  one  of  the  most  frequent  sites  of  sarcoma,  and 
sarcoma  is  the  most  frequent  tumor  of  bone.  It  is  oftenest  found 
in  the  femur,  tibia,  and  pehis.  The  tumor  may  grow  from  any  con- 
nective tissue  cells  in  the  bone,  but  not  from  myeloplaxes  nor  blood- 
forming  cells  (p.  113).  Bone  sarcomas  are  classified  clinically  as 
periosteal  and  medullary,  and  either  form  may  be  composed  of  round 


TUMORS  OF  HONE  447 

cells  or  spiiidU'  colls;  round-celled  sarconiiis  of  hone  most  t're(iuently 
are  derived  from  medullary  tissues,  where  round  cells  (lymphocytes, 
etc.)  are  found  normally;  while  periosteal  growths  are  most  fre- 
quently spindle-celled  in  tyi)e  (see  p.  IKi). 

Not  every  sarcoma  growing  in  bone  tends  to  form  osseous  tissue; 
many  of  them  remain  unossified  throughout,  and  some  do  not  have 
even  calcareous  deposits:  (1)  If  the  sarcoma  arises  from  connective 
tissue  cells  in  bone  (not  osteoblastic  in  type)  it  is  properly  called 
an  Qstco-sarcoma  (a  sarcoma  growing  in  hone);  (2)  such  as  are  derived 
from  bone-forming  cells  (osteoblasts)  alone  deserve  the  name  ossi- 
fi/ing  or  osteoid  sarcoma  (malignant  osteoma);  whereas  if  a  preexisting 
benign  tumor  of  bone  (osteoma,  chondroma,  myeloma?)  becomes 
sarcomatous  by  anaplasia,  it  is  termed  an  osteoma  {chondroma,  etc.) 
sarcomatodes.  In  the  first  and  last  varieties  no  true  bone  is  formed 
by  the  tumor  cells,  such  bone  as  is  present  being  either  the  original 
bone  invaded  by  the  tumor  cells,  or,  according  to  Borst  (1902),  may 
be  newly  formed  bone  due  to  stimulation  of  osteogenetic  cells  by  the 
adjacent  tumor  cells  (such  a 
stimulation  is  denied  by  Adami). 
The  histological  differentiation 
of  these  types  is  difficult,  and 
a  clinical  distinction  usually  is 
impossible;  but  as  the  prognosis 
depends  more  upon  the  type 
of  cell   from  which  the  tumor 

is  derived  than  on  the   form    of  .    J'^-  469.— Periosteal  ossifying  sarcoma  of 

^,  11      'j^     •      •  J.       J     J       1  index    metacarpal.     Age    forty-eight    vears; 

the  cell,    it     is    important    to   be  duration  six    weeks.     Amputation    of    fore- 

informed     that      a     pathological  arm      Death  thirty  months  later,  aft^r  three 

.         .  .  ^  Y  months   illness  from  pulmonary  metastases. 

distinction  exists  between  these  Episcopal  Hospital. 

forms  of   bone   sarcoma.     The 

most  malignant  growths  are  composed  of  the  most  highly  undiffer- 
entiated cells.  Thus  the  more  bone  in  a  sarcoma,  the  less  malignant 
it  is. 

Symptoms. — The  symptoms  of  sarcoma  in  general  are  given  at 
p.  117.  Medullary  or  central  sarcoma  usually  grows  in  the  meta- 
physes  of  the  long  bones,  and  for  a  time  is  prevented  by  the  epi- 
physeal cartilage  from  invading  the  joint.  The  patient  generally 
applies  for  pain  before  much  deformity  is  present.  Slight  uniform 
expansion  of  the  bone  end  may  be  found,  but  the  joint  is  not  impli- 
cated; in  early  stages  joint  motions  are  painless,  and  the  tumor 
pains  most  at  night,  not  during  exercise.  These  points  serve  to 
distinguish  it  from  arthritis.  Pathological  fracture  is  common, 
and  may  be  the  first  symptom.  It  is  a  question  whether  fracture 
ever  precedes  and  predisposes  to  sarcoma  formation.  A  skiagraph 
shows  total  destruction  of  the  bone  end,  but  a  normal  joint;  yet 
even  the  epiphysis  disappears  as  the  disease  advances.  Periosteal 
sarcoma,  usually  osteoid  in  character,  generally  affects  the  diaphyses 
of  long  bones,  early  causing  a  visible  swelling,  fusiform  in  outline. 


448 


DISEASES  OF  BONE 


but  situated  mostly  on  one  side  of  the  bone,  not  encircling  it.  It 
is  firm  but  not  bony  to  the  touch,  thus  being  easily  distinguished 
from  the  medullary  tumors  which  are  bony  hard  until  they  thin  the 
cortex  (stage  of  spina  ventosa)  or  break  through  it.  In  a  skiagraph 
the  periosteal  tumor  is  seen  to  be  caused  by  periosteal  proliferation, 
this  membrane  being  raised  from  the  shaft  rather  abruptly,  and  show- 
ing newly  formed  bone  in  the  wedge-shaped  chink  l)etween  itself 
and  the  cortex.  The  cortex  is  more  or  less  eroded  in  the  centre  of  the 
tumor  area,  and  in  advanced  cases  the  medulla  is  in^•aded.  Radiating 
spicules  of  newly  formed  osteoid  tissue  placed  at  right  angles  to  the 
shaft  are  present  between  the  cortex  and  raised  periosteum,  in  the 
centre  of  the  tumor. 


Fig.  470. — Periosteal  chondroma  sarcomatodes.  Age  fiftj-  years.  Tumor  for  twenty- 
five  years,  sudden  growth  for  three  months,  following  injury.  (See  Fig.  471.)  Refused 
any  operation.     Episcopal  Hospital. 

Diagnosis. — A  rather  rapidly  growing  (weeks  and  months)  tumor 
in  bone,  in  a  young  adult,  sometimes  following  trauma,  and  attended 
by  increasing  pain,  deformity,  and  disability,  usually  is  a  sarcoma. 
Local  heat,  enlarged  veins,  tense  shiny  skin,  etc.,  are  present  in 
advanced  cases.  In  case  of  doubt  it  is  well  to  measure  the  limb's 
circumference  accurately  at  intervals  of  a  few  weeks;  steady  and 
progressive  increase  in  circumference  denotes  a  malignant  neoplasm. 
Any  benign  tumor  of  bone,  even  if  in  existence  for  many  years,  which, 
from  trauma  or  no  known  cause,  begins  suddenly  to  grow  rapidly, 
should  be  considered  malignant  (Figs.  470  and  471). 

Treatment. — ^The  usual  advice  is  to  do  amputation  as  early  as 
possible,  the  limb  being  removed  at  the  nearest  joint  above  the  dis- 
ease.    But  to  one  who  considers  the  ultimate  results,  it  is  question- 


TUMORS  OF  BONE 


449 


able  whotluT  iuiythinj:;  is  ^niiiicd  by  this  l)iit  relief  of  i)iiiM.  Internal 
metastases  must  ofti'n  he  present  when  tiie  patient  first  comes  to 
the  siir^'eon,  since  they  appear  with  such  uniformitx'  even  after 
removal  of  the  limh;  and  local  recurrence  is  so  apt  to  follow  excisions 
or  amputation  in  continuity,  that  there  is  no  class  of  cases  so  dis- 


FiG.  471. — Skiagraph  of  periosteal  chondroma  sarcomatodes.  Same  case  as  Fig.  470. 
Tumor  for  twenty-five  years,  hard,  adherent  to  bone.  Three  months  ago  the  tumor 
was  broken  from  humerus  by  a  fall.  Since  then  there  has  been  rapid  growth,  and  much 
pain.    The  tumor  has  grown  fast  again  to  the  humerus.    Episcopal  Hospital. 


heartening.  ]Most  patients  die  within  two  or  three  years  from  the  first 
appearance  of  symptoms  of  the  disease.  The  object  of  any  opera- 
tion is  to  remove  all  of  the  tumor,  and  this  usually  but  not  always 
implies  disarticulation.  This  is  always  preferable  to  a  long  and 
bloody  excision  or  to  any  operation  which  will  leave  a  useless  limb. 
If  the  patient  regains  some  measure  of  health  and  comfort  even  for 
29 


450  DISEASES  OF  BONE 

a  few  months,  before  visceral  metastases  make  tlieir  presence  known, 
the  operation  cannot  be  said  to  have  })een  done  in  vain.  Coley's 
fluid  (p.  117)  should  be  employed  as  a  routine,  since  at  least  it  can  do 
no  harm,  and  may  be  of  value;  the  following  figures  give  Coley's 
own  experience  (1910)  with  its  use  in  sarcoma  of  long  bones:  of  52 
cases  in  which  it  was  used,  10  (6  myeloid  and  4  periosteal)  patients 
were  well  for  over  three  years;  of  3S  cases  in  which  it  was  not  used, 
5  (3  myeloid  and  2  periosteal)  patients  passed  the  three-year  limit 
in  good  health.  But  as  some  of  the  myeloid  sarcomas  included 
probably  should  have  been  classed  as  giant-celled  myelomas,  not  as 
sarcomas,  the  results  are  not  as  good  as  they  seem.  Opiates  should 
be  administered  freely  in  the  latter  stages. 

Carcinoma. — Carcinoma  of  bone  occurs  as  a  metastatic  growth, 
being  especially  frequent  in  cases  of  prostatic  and  thyroid  carcinoma, 
but  is  also  seen  in  carcinoma  of  the  mammary  gland,  uterus,  etc. 
In  the  long  bones  the  first  symptom  frequently  is  pathological  frac- 
ture, and  this  occurrence  always  should  lead  to  search  for  primary 
carcinoma,  past  or  present.  The  fractures  usually  unite  without  diffi- 
culty. In  the  spine,  secondary  carcinoma  usually  is  a  direct  extension 
from  mammary  or  visceral  carcinoma.  Local  treatment  is  useless. 
The  intolerable  pain  of  vertebral  in\'asion  should  be  relieved  by 
opium  given  until  effective;  or  the  dorsal  roots  of  the  nerves  may 
be  divided  intraspinally. 


CHAPTER    XV. 
DISEASES  OF  JOINTS. 

DYSTROPHIES  OF  JOINTS. 

Tr  was  pointt'd  out  in  the  last  chapter,  in  the  section  dealinii-  with 
Pi/.sfnipltir.s  of  Bone,  that  some  of  these  conditions  at  times  were 
associated  with  changes  in  the  organs  of  internal  secretion.  Thus, 
Acromegaly  is  very  constantly  associated  with  changes  in  the  hyi)ophy- 
sis  cerebri;  Achondroplasia  has  been  found  associated  with  patho- 
logical alterations  in  the  thyroid;  Osteogenesis  Im])erfecta,  with 
changes  in  the  adrenals;  Osteomalacia,  with  changes  in  the  ovaries, 
while  the  administration  of  thymus  or  thyroid  extract  sometimes  is 
of  benefit  in  cases  of  Osteitis  Deformans. 

As  in  the  case  of  bone  diseases,  so  in  those  w^hich  affect  the  joints, 
there  is  a  class  of  chronic  affections  not  definitely  inflammatory, 
though  possibly  due  to  remote  or  attenuated  infection,  to  toxemias 
or  intoxications,  or  to  changes  in  the  organs  of  internal  secretion. 
Until  more  definite  knowledge  concerning  them  is  gained,  it  is  con- 
venient to  class  them  as  dystrophies,  since  at  least  it  is  certain  that 
their  more  immediate  cause  is  to  be  sought  in  disturbances  of  nutrition. 
If  it  be  asked  why  disorders  due  to  disturbances  of  nutrition  affect 
the  bones  and  joints  rather  than  the  soft  parts,  it  may  be  replied 
that  the  bones  and  joints  have  a  less  free  and  active  circulation  than 
the  soft  parts,  and  like  the  hair,  nails,  teeth,  etc.,  give  early  evidence 
of  circulatory  disturbance;  moreover,  the  soft  parts  themselves  are 
affected,  but  less  conspicuously  than  the  bones  and  joints.  Slight 
constantly  recurring  injuries,  moreover,  show  their  effects  more  on 
the  joints  than  the  soft  parts,  and  sometimes  have  a  very  marked 
influence  in  localizing  trophic  lesions  in  one  joint  or  set  of  joints 
rather  than  in  others. 

The  pathological  changes  in  these  dystrophic  joints  are  those 
of  atrophy  and  hypertrophy;  they  may  exist  separately  or  together, 
but  in  almost  every  case  one  change  or  the  other  predominates  so 
that  the  disease  can  be  classed  either  as  atrophic  or  hypertrophic 
in  type.  It  is  possible  that  the  atrophic  type  is  a  more  acute  mani- 
festation of  the  same  disease  which  in  subacute  or  chronic  form  corre- 
sponds to  what  is  described  as  the  hypertrophic  type.  The  les  ons 
may  affect  the  synovial  membrane  only,  or,  as  is  much  more  fre- 
quently the  case,  the  bones  and  cartilages  as  well;  and  in  most  cases 
it  is  these  structures  which  are  first  involved,  the  synovial  membrane 
being  implicated  secondarily.  One  joint  or  many  may  be  affected, 
the  disease  being  classed  as  monarticular  or  polyarticular. 


452  DISEASES  OF  JOINTS 

The  noineiiclature  of  these  diseases  is  much  confused:  two  terms, 
Rheumatoid  Arthritis  and  Arthritis  Deformans  have  been  employed 
indiscriminately  by  many  wTiters,  and  have  been  applied  to  various 
different  diseases;  so  that  if  a  surgeon  today  refers  to  a  disease  by 
either  of  these  terms,  no  one  knows  to  what  disease  he  refers  unless 
he  further  defines  his  meaning.  Speaking  generally,  however,  the 
term  rheumatoid  arthritis  usually  has  been  applied  by  English-speaking 
physicians  to  chronic  joint  diseases  in  which  synovial  lesions  were 
believed  to  predominate;  and  osteo-arthritis,  or  arthritis  deformam, 
a  term  introduced  by  the  Germans,  to  those  forms  in  which  bony 
changes  are  preeminent.  The  relation  of  these  joint  dystrophies 
to  affections  of  the  organs  of  internal  secretion  is  by  no  means  so 
evident  as  in  some  of  the  bone  dystrophies,  to  which  reference  was 
made  above.  But  the  favorable  influence  exerted  by  a  long  course  of 
treatment  of  thymus  gland  extract  upon  atrophic  joint  lesions  is  well 
recognized,  and  the  development  of  hypertrophic  joint  lesions,  in 
women,  at  a  time  when  ovarian  and  thyroid  changes  are  frequent,  is 
a  fact  to  which  Llewellyn  Jones  recently  has  called  attention. 

It  is  customary  to  speak  of  all  these  joint  affections  as  different 
forms  of  artliritis,  though  this  term  implies  an  inflammatory  rather 
than  a  degenerative  condition.  Yet  these  dystrophic  joint  diseases 
have  certain  features  which  distinguish  them  from  infections  of  joints, 
and  which  it  is  \ery  important  to  bear  in  mind.  Our  present  knowl- 
edge of  the  subject  is  due  largely  to  the  investigations  of  Goldthwait, 
Xathan,  and  Llewellyn  Jones  (1909).  The  dystrophies  begin  insidi- 
ously, are  not  attended  by  marked  phenomena  of  inflammation  nor 
by  constitutional  reaction;  they  gradually  progress,  invading  other 
joints  one  by  one;  may  exhibit  slight  remissions  and  exacerbations; 
but  the  joints  once  aft'ected  never  entirely  recover,  and  there  is  no 
definite  end  to  the  disease.  The  infections  have  a  definite  and  easily 
remembered  commencement ;  are  attended  by  the  usual  inflammatory 
phenomena  and  constitutional  reaction,  even  if  slight  in  degree; 
usually  all  the  joints  affected  are  attacked  at  or  about  the  same  time; 
and  when  once  the  infection  has  run  its  course,  the  disease  is  gone, 
and  the  joints  recover,  or  retain  permanent  but  never  progressive 
disability. 

Atrophic  Joint  Lesions. — Here  is  placed  a  disease  named  "atrophic 
artliritis"  by  Goldthwait  (1905),  and  "metabolic  osteoarthritis" 
by  Nathan  (1906);  it  is  the  same  as  the  "rheumatisme  noueux"  of 
Trousseau  (1868),  the  "chronic  progressive  articular  rheumatism" 
of  Charcot  (1 874),  the  "arthritis  nodosa"  of  Waldmann  (1884),  the 
"arthritis  deformans"  of  Baumler  (1897),  and  the  "primary  progres- 
sive chronic  joint  rheumatism"  of  Pribram  (1902).  It  is  a  poly- 
articular, symmetrical  affection,  occurring  in  women  oftener  than 
in  men,  and  generally  beginning  in  the  fingers  and  hands,  where  it 
may  be  localized  by  repeated  slight  trauma.  It  is  seen  oftenest  in 
young  adults,  but  sometimes  occurs  in  children.  It  affects  first 
the   smaller  joints   of   the  hands   and   feet,  especially  the  proximal 


ATh'Ol'UIC  JOINT   LESIONS 


453 


iiitcrpliiihiiiiical  joints  of  the  fin<jers;  it  profjresscs  through  muny 
years,  iii\a(liii<f  the  wrists,  dhows,  shoulders,  ankles,  knees,  spine, 
and  maxillary  joints.     'J'he  hips  seldom  are  aiVeeted. 

The  pathological  ehan<:;e  first  noted  is  a  localized  suhclujndral  atrophy 
of  the  joint  ends,  fjiving  them  a  "])unched  out"  appearance  in  a 
skiai^ram  (Fiij.  472);  these  are  minute  jjone  cysts,  due  to  osteoporosis 
and  lacunar  resorption  (Nathan,'  1!)(M)).  Later  the  overlyin^f  cartila<;e 
degenerates,  becomes  invaded  by  comiective  tissue  from  the  un<ler- 
lying   s])ongiosa,   and   a   so-called   cartilaginous  decubitus    (pressure 


Fig.  472. — Skiagraph  of  atrojjhic  arthritis  of  liands.  Girl,  agf^d  twenty-one  years; 
duration  two  yeans.  Note  bone  cyst  in  distal  end  of  proximal  phalanx  of  middle  finger 
of  left  hand;  absorption  of  heads  of  metacarpal  bones  in  both  hands;  and  atrophic 
changes  in  bones  of  right  carpus.     Orthopaedic  Hospital. 

sore)  is  produced  by  pressure  of  the  opposing  bone.  The  cartilage 
becomes  completely  absorbed,  the  joint  cavity  is  lost,  being  filled 
by  loose  and  vascular  connective  tissue  which  shows  no  tendency  to 
contraction,  and  ankylosis  (p.  467)  rarely  or  never  occurs.  In  skia- 
graphs of  advanced  cases  the  joints  appear  to  be  ankylosed,  because 
the  bones  are  in  immediate  contact  or  overlap,  no  clear  cartilaginous 
area  intervening  (Fig.  473).  The  joints  become  distorted,  and  sub- 
luxated  from  muscular  contraction;  and  in  weight-bearing  joints,  as 

1  Poncet  considers  such  changes  characteristic  of  one  form  of  "tuberculous 
rheumatism"  (see  p.  474). 


454 


DISEASES  OF  JOINTS 


the  knee,  tlie  bone  ends  may  become  broadened  and  mashed  out 
rather  flat,  owhig  to  their  atrophic  state.  No  reactionary  phenomena 
are  visible;  no  attempts  at  repair  are  made;  no  ecchondroses  or  osteo- 
phytes are  formed. 


Fig.  473. — Skiagraph  of  atrophic  arthritis  of  hands.  Woman,  aged  thirty  years; 
(hiration  five  years.  Changes  more  advanced  than  in  Fig.  472.  .Subluxations  and 
api)ar(>iit  ankyloses.    (See  Fig.  474.)   Orthopaedic  Hospital. 

Symptoms  — The  pathological  changes  shown  in  Fig.  472  may 
ha\e  existed  for  many  months  before  subjective  symptoms  arrest  the 
])atient's  attention.      Usually  the  first  complaint  is  of   stift'ness  in 


Fig.  474. — Atrophic  arthritis.     Duration  six  years.    Same  patient  as  in  Fig.  47."i. 


the  fingers,  worse  in  the  morning  and  gradually  passing  away  after 
use;  and  the  patient  is  dosed  for  "rheumatism."  But  on  examina- 
tion this  is  found  not  to  be  real  stiffness,  but  rather  weakness,  passive 


ATROPHIC  JOINT  LESIONS 


45: 


motion  being  free  and  often  i)ainless.  Muscular  atrophy  is  pro- 
nounced, and  often  increased  the  swollen  appearance  of  the  joints 
{V'l'j,.  474).  Synovial  cIVusion  is  rare,  except  from  o\er-exertion  or 
trauma;  it  may  he  attended  i)y  considerable  pain,  but  l)oth  pain  and 
effusion  subside  when  the  joints  are  put  at  rest.  Joint  deformity 
follows  destruction  of  l)one  ends  and  muscular  contraction;  but 
thouiih  motion  may  be  limited  or  even  ai)olished  by  periarticular 
changes  it  is  free  within  the  range  allowed.     ^Motion  is  most  limited 


Fig.  475. —  Skiagraph  of  atrophic  arthritis  of  hands,  advanced  stage.  Woman,  aged 
sixty-five  years;  duration  forty-five  years.  Marked  bone  absorption,  many  subluxa- 
tions. Two  years  later  skiagraphs  showed  scarcely  any  bone  left  in  shafts  of  meta- 
carpals.    (See  Fig.  476.)  Episcopal  Hospital. 

in  the  larger  joints;  in  advanced  cases  the  smaller  joints  may  become 
flail-like,  and  the  skin  covers  the  phalanges  like  a  wrinkled  glove 
(Figs.  47.3  and  476).  Lateral  deviation,  flexion,  or  hyperextension  of 
the  phalanges  may  occur,  and  several  dift'erent  deformities  may  exist 
in  the  same  hand.  The  only  constitutional  symptoms  are  those  of 
slight  cachexia  and  secondary  anemia. 

Prognosis. — The  prognosis  is  gloomy.  The  disease  steadily  pro- 
gresses, and  in  most  cases  the  patient  eventually  becomes  a  helpless 
cripple. 


456  DISEASES  OF  JOINTS 

Treatment. — Good  feeding  and  hygiene  are  reqnired;  tlie  only 
favorable  results  I  have  seen  have  been  in  patients  under  the  care 
of  Pemberton,  whose  plan  of  treatment  is  based  on  metabolic 
studies,  and  is  largely  dietetic  in  nature  (1913).  Medicines  are  of 
little  value,  but  Nathan  reports  increasingly  favorable  results  from 
thymus  extract,  in  doses  of  10  to  20  grains  three  times  daily.  Guaiacol 
carbonate  sometimes  is  useful,  in  doses  of  from  5  to  15  grains  three 
times  daily,  continued  for  at  least  a  year.  This  should  be  combined 
with  potassium  iodide  and  tonics.  Rest  is  necessary  when  exacerba- 
tions occur  from  trauma  or  over-use;  it  often  is  best  enforced  by 
use  of  orthopedic  apparatus.  Massage,  hot  baths,  baking,  etc.,  and 
exercise  short  of  fatigue,  are  of  some  value.  After  subsidence  of  acute 
symptoms,  deformity  should  be  corrected  by  weight-extension  and 
tenotomy,  or  even  by  forcible  manipulation,  though  this  is  more  apt 
to  fracture  the  bones  than  overcome  periarticular  contractures. 


Fig.  476. — Atrophic  arthritis  (advanced  stage).    Same  patient  as  Fig.  475. 
Episcopal  Hospital. 

Hypertrophic  Joint  Lesions.— These,  as  pointed  out  at  p.  550, 
are  not  rare  as  results  of  attenuated  or  remote  infections;  but  there 
are  also  certain  forms  of  hypertrophic  joint  disease  which  seem  to 
be  pure  disorders  of  nutrition.  In  the  polyarticular  form,  "Ileber- 
den's  nodes"  (1804)  are  found;  these  consist  essentially  in  hyper- 
trophies of  the  bases  of  the  distal  digital  phalanges,  often  accom- 
panied by  lateral  deviation  of  the  terminal  phalanx  (Fig.  477).  The 
thumb  rarely  is  affected.  The  monarticular  form  is  of  more  interest 
to  surgeons.  It  is  the  "arthritis  deformans"  of  Volkmann  (1882), 
Schiiller  (1900),  and  Hoffa  (190G),  the  "chronic  partial  rheumatism" 
of  Charcot  (1874),  and  the  "hypertrophic  arthritis"  of  Goldthwait 
(1905).  In  this  disease  the  influence  of  trauma  frequently  is  con- 
spicuous, hypertrophic  lesions  developing  in  a  joint  injured  perhaps 
many  years  before  (Fig.  402),  or  in  one  which  constantly  is  subject  to 
slight  injury  or  strain.  Static  strain,  from  imperfectly  reduced  fracture, 
or  faulty  attitudes,  often  is  a  cause.  The  disease  affects  men  more 
than  women,  usually  those  past  forty  years;  and  arteriosclerosis  seems 
to  be  a  predisposing  factor.  Sometimes  the  affection  is  called  senile 
arthritis,  and  when  the  hip  is  attacked,  it  is  known  as  "morbus  coxae 


HYPERTh'OI'llIC  JOINT   LEGIONS 


457 


senilis."  As  ;i  matter  of  fact,  liowexcr,  the  knee  is  more  often  aifeeted 
than  the  hi|),  especially  in  women;  in  men  the  hi])  and  spine  arc 
oftener  attacked.  in  the  spine  the  disease  is  called  " sj)ondylitis 
deformans"   (j).  (il(i). 

Tlie  earliest  path()U)gieal  cliange  is  said  to  oeenr  in  the  joint  car- 
tihifje;  this  shows  attemj)ts  at  proliferation,  hnt  the  cartila<i;e  eells 
which  border  on  the  joint  cavity  are  discharged  into  the  synovial 
finid,  and  the  nnderlyini;-  eartila«i;e  is  worn  down  by  attrition  of  the 
opposing  hone,  i)rodncing  a  "cupping"  of  the  joint  surface;  while 


Fig.  477. — Skiagraph  of  hands  of  patient,  aged  sixty-three  years,  with  ijoljarticuhir 
hypertrophic  arthritis.  Insidious  onset,  many  years  ago.  Note  hyjKTtroijhies  f)f  liases 
of  distal  phalanges  ("Heberden's  nodes")  and  periosteal  proliferations  along  shafts  of 
proximal  and  middle  phalanges.     Orthopaedic  Hospital. 


the  more  fortunate  cartilage  cells  not  subjected  to  such  pressure 
proliferate  into  the  attachments  of  the  capsule,  and  so  produce  spurs, 
ecchondroses,  and  osteophytes,  which  cause  a  "lipping"  at  the  joint 
margins.  The  bone  ends  themselves  often  are  the  seat  of  porosis, 
and  in  weight-bearing  joints,  especially  the  hip,  very  marked  altera- 
tions in  the  shape  of  the  bone  ends  may  occur;  thus  the  head  of  the 
femur  may  be  worn  away,  the  acetabulum  enlarged  upward  and 
backward  ("wandering  acetabulum"),  while  the  base  of  the  femoral 
neck  and  the  acetabular  borders  become  studded  with  osteophytes. 


458 


DISEASES  OF  JOINTS 


The  angle  between  the  neck  and  shaft  of  the  femur  is  decreased,  and 
coxa  vara  results.  The  earliest  skiagraphic  evidences  of  these  bone 
changes  are  observed  in  shari)er  angularity  of  the  bone  margins. 
The  edges  of  the  tibial  condyles  become  sharj),  the  patella  becomes 
square,  the  astragalus  and  scaphoid  lose  their  gentle  curves,  and 
eventually  distinct  exostoses  are  observed  (Figs.  478  and  479).  These 
occur  especially  at  points  of  strain,  where  ligaments  or  tendons  are 
attached ;  they  are  not  always  confined  to  the  immediate  neighborhood 
of  joints.     The  joint  ligaments  may  be  gradually  destroyed  by  the 


Fig.  47S. — Skiagraph  of  monarticular  hypertrophic  arthritis  of  knee.  Woman,  aged 
forty-nine  years.  Duration  two  years.  Insidious  onset;  no  injury.  (See  Fig.  479.) 
Orthopa?dic  Hospital. 

degenerative  process,  and,  according  to  Marsh,  the  joint  may  become 
weakened,  loose,  even  flail-like;  this  occurs  oftenest  in  the  knee. 
Usually,  however,  for  a  time  at  least,  limitation  of  motion  is  observed 
owing  to  periarticular  fibrous  changes  or  the  interlocking  of  osteo- 
phytes, but  ankylosis  rarely  or  never  occurs.  If  the  obstructing 
osteophytes  are  removed,  free  motion  may  be  restored  for  a  time. 
In  the  shoulder-joint  the  long  tendon  of  the  biceps  may  fuse  with 
the  underlying  bone. 

Symptoms. — The  patient  complains  of  weakness  and  stiffness  in 
the  affected  joint.     It  creaks  on  motion,  and  motion  commonly  is 


IJYl'PJin'h'ol'lllC  JOIST   LESIONS 


459 


limited.  Srvere  referrorl  pain  as  woll  as  local  pain  may  hv  IVlt.  The 
uciicral  health  is  not  materially  imi)aire(l.  If  the  small  joints  are 
alVeeted  the\  present  Hehenlen's  nodes,  hnt  rarely  {jjive  snhjective 
symptoms.  Tlie  disease  tyi)ieally  is  monarticular  in  the  beginning, 
and  often  remains  so;  but  other  joints  may  be  involved  in  time.  The 
(ll(i(lii(i.s-is  depends  on  excluding  an  infectious  origin,  whicli  often  is 
dilhcult,  and  sometimes  impossible;  on  observing  the  localization 
of  the  process  to  one  of  the  larger  joints  which  has  ])een  injured  or 
is  the  seat  of  constant  strain  or  reix'ated  slight  trauma;  and  on  the 


Fig.  479. 


-Hj-pcrtrophic  arthritis  of  knee,  lateral  view.     Same  patient  as  Fig.  478. 
Orthopjedic  Hospital. 


results  of  skiagraphic  examination.  Atrophic  arthritis  is  polyar- 
ticular, aflfects  first  the  smaller  peripheral  joints,  and  spreads  cen- 
tripetally,  and  occurs  in  women  in  early  adult  life.  Hypertrophic 
arthritis  is  monarticular,  affects  a  large  joint,  and  occurs  in  persons 
past  middle  life.  Both  have  an  insidious  onset,  are  chronic  from  the 
start,  run  a  long  and  tedious  course,  and  neither  is  accompanied  by 
inflammatory  or  constitutional  symptoms. 

Treatment. — Sometimes  it  may  be  possible  to  prevent  the  devel- 
opment  of   hypertrophic  lesions   by  relieving   a   joint   from  strain, 


460 


DISEASES  OF  JOINTS 


protecting  it  from  injury,  or  by  active  treatment  of  an  underlying  con- 
dition, such  as  internal  derangement  of  the  knee-joint  (p.  412).  In  the 
cure  of  the  disease,  a  painful  joint  should  be  put  at  rest.  Confinement 
to  bed  seldom  is  necessary,  the  use  of  plaster  of  Paris  splints,  braces, 
etc.,  usually  being  sufficient.  Imm()l)ilization  should  not  be  a})Solute, 
however,  nor  should  it  be  continued  too  long,  since  this  promotes 
stiffness.     Such  exercises  as  can  be  taken  without  too  great  fatigue 

should  be  encouraged.  Occasionally 
one  or  more  bony  spurs  which 
markedly  limit  motion,  or  cause 
pressure  symptoms,  may  be  re- 
moved by  saw  or  chisel.  Arthro- 
desis (p.  528)  has  been  employed 
in  some  cases,  especially  at  the 
hip  (Figs.  480  and  481)'  and  the 
knee,  to  relieve  pain  by  permanent 


Fig.  480. — Albee's    method  of    arthro- 
desis of  the  hip     (See  Fig.  481.) 


Fig.  481. — Albee's  method  of  arthro- 
desis of  the  hip. 


Fig.  482. — Charcot  joint.  Age  fifty-one 
years.  Duration,  three  months;  followed 
sprain  while  climbing.  Lost  knee-jerks  and 
Argyll-Robertson  pupils.  Orthopaedic  Hos- 
pital. 


joint-fixation.    General  hygienic  treatment  is  of  value,  but  no  drug 
has  much  influence  on  the  disease. 

Neuropathic  Joints  (Charcot,  1868). — In  tabes  dorsalis  the  joints 
are  subjected  to  unusual  strain,  as  deep  sensation  is  lost,  and  the 
patient  is  not  aware  of  the  injury  he  inflicts  upon  them  in  walking, 
pulling  himself  up  stairs,  etc.;  the  nutrition  of  the  bones  also  is  dis- 
turbed, predisposing  them  to  distortion  and  fracture.  So-called 
spontaneous  fracture  is  not  rare,  and  sometimes  occurs  some  time 


INFECTIONS  OF  JOINTS  461 

hc'l'ori'  (Iclinitc  talx'tic  syiuptoms  doxolop.  As  a  rule  only  one  joint  is 
afVec'trd  hy  the  dystrophy,  most  often  the  knee;  hut  the  shoulder, 
elhow,  aid<l('.  and  hi])  soinetinies  are  att'eeted.  Painless  effusion  may 
he  the  first  synii)toin,  and  this  may  exist  so  lon^  as  to  induce  relaxation 
of  the  lii:;ainents,  or  even  a  flail-joint,  hefore  the  patient  realizes  its 
condition  (Fi^-  1''^-).  The  hone  ends  heeome  distorted  from  pressure, 
and  pieces  may  he  hroken  oft'  and  lie  free  in  the  joint.  Osteophytes 
fre((nentl.\'  \:^to\\'  in  the  fihrous  tissues  surroun(Hnj!;  the  joint. 

Diagnosis. — The  diagnosis  de{)en(ls  on  the  detection  of  constitu- 
tional symptoms  of  tahes,  associated  with  a  nearly  painless  dystrophy 
of  one  of  the  larger  joints,  with  ettusion  and  ahnormal  mohility. 
In  synngoimjcUa  similar  changes  may  occur,  usually  in  the  upper 
extremity. 

Treatment. — This  consists  in  care  of  the  general  tahetic  conditi(jn, 
and  support  to  the  diseased  joint;  massage  may  improve  the  con- 
dition of  the  surrounding  muscles.  In  some  cases  arthrodesis  may  he 
done,  in  the  endeavor  to  restore  stahility.  Very  rarely  amputation 
may  he  required. 

LOOSE  BODIES  IN  JOINTS. 

This  condition  has  many  of  the  same  symptoms  as  interned  drranqc- 
mcnt  of  the  knee-joint,  referred  to  at'  p.  412,  but  the  patliogenesis 
is  dift'erent.  The  knee  is  affected  in  the  vast  majority  of  cases.  The 
loose  bodies,  or  "joint  mice"  as  they  are  called,  may  be  entirely  free, 
or  may  remain  atfacKecTto  the  capsule  by  a  pedicle.  They  may  be 
deri\ed  from  hypertrophied  synovial  fringes,  from  organized  blood- 
clot,  flakes  of  fibrin,  etc.;  from  detached  chips  of  bone  or  cartilage; 
or  from  ecchondroses,  osteophytes,  etc.,  developed  in  hypertrophic 
arthritis.  One  or  an  innumerable  number  of  such  bodies  may  be 
present. 

Symptoms.  —  The  symptoms  are  those  of  the  underlying  disease 
(villous,  or  hypertrophic  arthritis),  or  of  old  injury,  wdth  occasional 
locking  of  the  joint  from  impaction  of  the  loose  body.  This  often 
is  followed  by  an  attack  of  acute  synovitis.  If  the  loose  bodies  are 
large,  or  present  in  sufficient  numbers,  they  may  be  detected  by 
palpation,  and  sometimes  they  are  dense  enough  to  be  detected  in  a 
skiagraph.  .  Care  should  be  taken  not  to  mistake  a  normal  sesamoid 
bone  or  other  extra-articular  structure  for  a  loose  body. 

Treatment. — Usually  nothing  short  of  arthrotomy  and  remo\al 
of  the  bodies  will  give  relief,  unless  the  joint  is  kept  immobilized; 
and  even  after  such  an  operation  the  joint  lesion  which  caused  the 
formation  of  the  loose  bodies  will  recpiire  its  appropriate  treatment. 

INFECTIONS  OF  JOINTS. 

Pathology. — Infection  may  reach  a  joint  through  external  wound, 
directly  through  the  blood-stream,  or  from  a  neighboring  focus  of 


462 


DISEASES  OF  JOINTS 


inflammation,  usually  in  bone.  Wounds  of  joints  have  been  considered 
in  Chapter  XIII.  ]\Iost  joint  infections  secondary  to  bone  lesions 
are  tuberculous  in  origin;  these  are  discussed  at  (p.  476).  In  this 
place  it  is  desired  merely  to  enumerate  briefly  the  main  pathological 
changes  which  occur  in  joints  as  the  result  of  infection. 

Synovitis  is  the  earliest  stage;  the  synovial  membrane  is  congested 
and  swollen,  and  minute  ecchymotic  areas  may  be  present  in  it; 
effusion  into  the  joint  cavity  occurs,  due  both  to  increase  in  the 
natural  synovial  secretion  and  to  the  formation  of  inflammatory 
lymph.  Fluid  collects  in  the  joint  because  it  is  a  free  surface,  and 
wherever  a  free  surface  exists  effusion  predominates  over  edema. 
In  mild  infections,  and  in  aseptic  inflammations  such  as  sprains, 
contusions,  etc.,  the  eflfused  fluid  usually  remains  serous  in  type;  but 
infections  due  to  pyogenic  cocci  usually,  and  those  caused  by  the  pneu- 
mococcus,  gonococcus,  etc.,  often  end  in  suppuration,  constituting 
the  condition  of  liyarthrosis  or  empyema  articidi  (Fig.  483).  Arthritis 
is  a  clinical  term  used,  in  contradistinction  to  synovitis,  to  imply 
predominant  involvement  of  structures  of  the  joint  other  than  the 
synovial  layer  of  the  capsule;  and  osteo-arthritis  signifies  involvement 


Fig.  483. — Pyarthrosis  of  wrist.     Residual  abscess  three  months  after  complete 
healing  of  infected  hand  and  forearm.     Orthopsedic  Hospital. 


of  the  bone  ends.  In  some  cases  of  subacute  infection  no  marked 
effusion  occurs,  but  proliferation  of  the  synovial  villi  is  the  main 
feature,  producing  villous  arthritis;  this  is  believed  by  some  to  be 
caused  by  a  specific  diplococcus,  discovered  in  1900  by  Schiiller. 

If  recovery  ensues  while  the  eft'usion  is  still  serous,  little  subse- 
quent trouble  may  be  experienced;  often,  however,  the  fluid  is  not 
entirely  absorbed,  and  chronic  serous  synovitis  {hydrops  articidi,  p.  464) 
develops.  When  the  exudate  has  been  sero-fibrinous  some  organiza- 
tion of  the  inflammatory  material  usually  occurs,  and  the  joint  ca\ity 
is  more  or  less  obliterated  by  bands  of  adhesions,  which  may  restrict 
motion.  When  suppuration  has  occurred,  more  or  less  destruction 
of  the  cartilages,  ligaments,  etc.,  is  inevitable;  complete  disorganiza- 
tion of  the  joint  may  occur;  and  as  gradual  repair  by  organization 
and  cicatrization  sets  in,  the  bones  become  welded  together,  more  or 
less  firmly,  and  frequently  in  bad  position,  in  a  condition  of  ankylosis 
(p.  467).  Ankylosis  may  be  entirely  bony,  or  due  to  fibrous  adhesions 
allowing  a  very  limited  range  of  motion;  limitation  of  motion  due  to 
periarticular  changes  (contraction  of  capsule,  ligaments,  tendons; 
locking  of  osteophytes,  etc.)  is  not  spoken  of  as  ankylosis,  which  term 


SYXOVITIS   AND   Aia'llUlTlS  M).\ 

al\va\s  implies  loss  of  motion  from  intra-artlculur  adhesions,  iihrcnis  or 
osseous  in  character.  Owing  to  the  distention  of  the  capsule  during 
the  stage  of  effusion,  and  to  changes  in  the  hone  ends,  patholofiiral 
dislocation  of  the  joint  may  occur,  from  muscular  action,  or  the 
force   of   gravity. 

S3rmptoms. — Joint  effusion  is  shown  by  increase  in  circumference, 
with  bulging  of  the  capsule  at  its  weakest  parts.  In  the  knee  the 
j)atella  is  floated  up  from  the  condyles,  and  when  the  cjuadriceps 
extensor  is  relaxed,  the  i)atella  can  be  made  to  taj)  against  the  bone; 
the  capsule  bulges  on  each  side  of  the  quadriceps  tendon,  and  the  quad- 
riceps bursa  is  distended  (Fig.  484).  When  much  fluid  is  present 
fluctuation  can  be  elicited.  In  the  elbow  the  capsule  l)ulges  on  both 
sifles  of  the  triceps  tendon;  in  the  ankle,  beneath  the  tendo  Achillis 
and  anteriorly.  In  the  wrist  swelling  is  more  marked  on  the  dorsum; 
while  in  the  hip  and  shoulder  effusion  is  more  difficult  to  appreciate. 
Any  joint  which  is  the  seat  of  effusion  tends  to  assume  a  position 
in  which  the  capsule  is  most  relaxed;  this  usually  is  in  moderate 
flexion,  and  in  the  hip  slight  abduction  as  well  as  flexion  is  charac- 
teristic. Great  pain  is  felt  in  the  affected  joint,  and  from  pressure 
of  the  effusion  on  neighboring  nerves  referred  pain  may  exist.  ^lus- 
cular  spasm  is  present,  and  may  cause  starting  or  jumping  pains 
in  the  joint,  from  time  to  time,  especially  during  sleep.  Joint  motion 
is  painful,  and  the  joint  itself  is  tender.  As  a  rule,  the  bone  ends  are 
not  tender  in  simple  synovitis  nor  in  arthritis  not  secondary  to  osseous 
disease;  but  crowding  the  bones  together  causes  pain.  The  affected 
joint  may  be  hot  even  in  simple  synovitis,  but  unless  suppuration  is 
present  there  is  not  much  constitutional  disturbance,  nor  is  the 
affected  joint  red.  Suppuration  may  be  ushered  in  by  a  chill,  or  there 
may  be  no  change  except  in  the  temperature.  In  pyarthrosis  of  the 
larger  joints  the  patient  becomes  gravely  ill,  and  all  the  constitutional 
signs  of  septicemia  or  pyemia  develop.  The  joint  becomes  more  tense 
and  painful,  exquisite  tenderness  develops,  dusky  redness  with  edema 
of  the  skin  may  be  present,  and  unless  the  pus  is  evacuated  it  may 
perforate  the  capsule  and  invade  the  soft  parts.  Spontaneous  dis- 
location is  most  frequent  in  the  hip. 

If  villous  arthritis  develops,  the  joint  does  not  present  fluctuation, 
but  is  doughy,  and  the  capsule  does  not  bulge  but  presents  a  more 
uniform  enlargement,  and  it  is  evident  that  this  is  due  partly  to  peri- 
articular thickening.  The  condition  becomes  subacute  or  chronic, 
and  is  then  characterized  b}'  creaking  and  crackling  on  motion,  slight 
permanent  loss  of  full  extension,  and  moderate  disability. 

Treatment. — The  treatment  of  acute  synovitis  consists  in  local 
rest  of  the  joint,  secured  by  proper  splinting,  and  in  the  case  of  the 
lower  extremity  by  rest  in  bed,  usually  with  weight  extension.  If 
this  treatment  is  instituted  promptly,  apparent  recovery  may  ensue 
in  a  few  days;  but  the  joint,  especially  the  knee,  should  be  protected 
for  several  weeks  by  a  light  plaster  case,  as  recurrence  of  effusion, 
and  development  of  hydrops  is  much  to  be  feared.    ^lassage  of  the 


464  DISEASES  OF  JOINTS 

surrounding  muscles,  not  of  the  joint  itself,  is  of  value  for  restoration 
of  function  after  all  inflammatory  symptoms  have  been  absent  for 
several  weeks.  When  the  patient  comes  under  observation  at  a 
later  stage,  with  the  joint  in  bad  position,  or  suppuration  threatening, 
weight  extension  should  be  applied  as  well  as  splinting;  the  latter 
alone  sometimes  is  sufficient  for  the  upper  extremity.  The  joints 
should  be  kept  in  the  position  which  will  be  least  useless  should 
ankylosis  occur:  the  shoulder  in  slight  abduction;  the  elbow  and 
ankle  at  a  right  angle;  the  wrist  and  knee  in  full  extension;  and  the 
hip  in  full  extension  and  slight  abduction,  but  without  either  external 
or  internal  rotation.  The  forearm  should  be  kept  nearly  in  full 
supination. 

Suppuration  is  treated  by  aspiration  (which  may  be  used  as  a 
diagnostic  measure)  and  injection  of  2  per  cent,  formalin-glycerin 
solution,  the  joint  meantime  being  kept  at  rest,  and  such  constitu- 
tional measures  being  used  as  the  patient's  condition  demands. 
Aspiration  and  formalin  injection  may  be  repeated  a  number  of  times, 
though  the  injection  may  be  very  painful;  and  usually  the  infection 
may  be  controlled  in  this  way,  the  fluid  gradually  becoming  serous, 
and  the  joint  inflammation  subsiding  with  preservation  of  a  fair 
degree  of  motion.  Should,  however,  improvement  not  be  secured 
after  two  or  three  aspirations,  the  joint  should  be  incised,  and  treated 
as  detailed  for  septic  arthritis  following  trauma  (p.  387). 

Villous  artliritis,  when  acute,  is  treated  as  synovitis,  by  rest,  and 
antiphlogistic  or  sorbefacient  applications.  In  its  more  usual  sub- 
acute or  chronic  stage,  benefit  is  derived  from  massage,  passive 
motion,  baking,  hot  and  cold  douches,  passive  congestion,  etc.  Any 
source  of  infection  (see  p.  47(3)  should  be  removed,  and  the  patient's 
general  health  improved.  Painful  joints  should  be  supported  by 
suitable  apparatus. 

Acute  Arthritis  of  Infants  (T.  Smith,  1874)  almost  invariably  sup- 
purative, occurs  as  a  hematogenous  infection,  and  probably  always 
is  secondary  to  acute  epiphysitis  (p.  43(3).  The  diagnosis  is  not 
always  easy,  unless  the  condition  is  constantly  in  mind;  when  the 
pus  has  perforated  the  capsule,  making  beneath  the  muscles  a  tense, 
hot,  painful  swelling,  with  enlarged  veins,  a  diagnosis  of  sarcoma  has 
often  been  made.  I  saw  such  an  error  in  an  infant  with  arthritis  of 
the  shoulder,  when  I  was  house-surgeon  at  the  Episcopal  Hospital. 
The  disease  seldom  results  in  ankylosis,  but  leaves  a  deformed, 
flail-like  joint. 

Chronic  Serous  Synovitis,  or  Hydrops  Articuli,  occurs  oftenest 
in  the  knee,  usually  the  result  originally  of  slight  trauma  causing 
acute  synovitis  with  efl'usion,  which  has  never  entirely  subsided, 
owing  to  inefficient  treatment,  for  which  the  patient  is  more  often 
to  be  blamed  than  the  surgeon.  The  condition  is  maintained  either 
by  recurring  slight  trauma,  or  by  some  remote  or  attenuated  infec- 
tion. Sometimes  hydrops  seems  to  be  chronic  from  the  start;  in 
such  cases  careful  search  should  be  made  for  anv  site  of  infection 


nV DROPS   AHTICULI 


41  ;r) 


which  may  maintain  a  toxemia  and  tiius  interfere  witii  joint  metab- 
olism. 

The  joint  is  distended,  but  rarely  tense;  floatinj^  of  the  patella 
and  fluctuation  are  detected  easily;  and  no  signs  of  acute  inflammation 
or  constitutional  disturbance  are  present  (Fig.  4S4).  If  pain  is  entirely 
absent,  the  existence  of  a  Charcot  joint  should  be  suspected  (p.  4G0). 
The  patient  complains  of  weakness  and  insecurity  in  the  knee,  of  its 
tiring  easily,  of  a  feeling  of  fulness  and  discomfort  on  partial  flexion, 
and  of  inability  to  flex  the  joint  completely.  He  stands  usually  with 
the  knee  not  quite  fully  extended, 
though  passive  extension  may  produce 
no  discomfort.  There  may  be  a  mod- 
erate degree  of  villous  hypertrophy,  and 
"joint  mice"  may  develop;  indeed  such 
conditions  themselves  may  maintain  a 
state  of  chronic  synovitis  by  the  con- 
stant irritation  they  produce.  Increase 
in  the  pads  of  subpatellar  fat  is  not 
unusual  (see  Lipoma  Arhorescens,  p. 
503);  and  the  neighboring  bursse  may 
be  clironically  inflamed. 

Treatment. — Any  source  of  infection 
which  can  be  detected  should  be  cured, 
and  intestinal  putrefaction  and  toxemia 
should  be  overcome  if  present.  Localh', 
treatment  should  be  instituted  as  for 
acute  synovitis,  by  putting  the  joint 
at  absolute  rest  for  several  weeks. 
This,  wqth  moderate  uniform  pressure 
by  plaster  of  Paris  or  adhesive  strap- 
ping, may  cause  the  effusion  to  dis- 
appear. Counter-irritation  may  assist 
absorption.  It  may  now  be  possible 
to  detect  a  loose  cartilage  or  other 
form  of  "joint  mouse"  wdiich  is  partly 
responsible  for  continuance  of  the  condi- 
tion. Rarely  aspiration  of  the  fluid  may 
be  employed  for  the  same  purpose,  and 

to  hasten  absorption;  it  should  be  followed  by  injection  of  2  per  cent, 
formalin  glycerin  solution.  I  once  did  arthrotomy,  finding  the  under 
surface  of  the  patella  and  opposing  femoral  cartilage  roughened,  and 
placed  a  drainage  tube  across  beneath  the  patella;  the  patient  recovered 
perfect  function  in  a  few  weeks,  and  in  the  eight  years  he  was  under 
observation  there  was  no  return  of  the  condition,  which  had  resisted 
conservative  treatment  for  months.  Such  a  plan  rarely  is  proper, 
because  the  disabilit}^  never  is  total,  and  the  disease  entails  no  risk 
to  life.  If  rest  and  immobilization  fail  to  secure  absorption  of  the 
fluid,  or  if,  as  is  usual,  eft'usion  recurs  when  joint  function  is  resumed, 
30 


Fig.  484. — Hydrops  articuli  of 
left  knee,  slight  of  right.  Gonor- 
rheal arthritis  of  left  knee  twelve 
years  ago.  Knee  always  swollen 
since.     Orthopaedic  Hospital. 


466  DISEASES  OF  JOINTS 

the  patient  may  be  allowed  to  walk  about  in  a  gypsum  case  or  brace; 
and  hot  and  cold  douches,  vigorous  massage  of  the  joint  and  leg  and 
thigh  muscles  during  many  months,  and  elastic  compression  may 
bring  a  certain  measure  of  relief.  When  joint  mice  are  present,  they 
may  be  removed  by  arthrotomy,  in  the  hope  that  they  are  the  cause 
of  the  recurring  effusion.  It  is  rare  for  a  permanent  cure  to  be 
obtained. 

Intermittent  Hydrarthrosis  is  a  very  obscure  affection  of  joints, 
generally  believed  to  be  of  vaso-motor  origin.  The  effusion  occurs 
suddenly,  within  a  few  hours,  and  subsides  as  rapidly,  or  within  a 
day  or  two ;  the  attacks  occur  at  more  or  less  regular  intervals,  perhaps 
daily  for  a  certain  portion  of  each  year,  or  every  few  months.  Almost 
any  joint  may  be  afl'ected,  and  men  as  well  as  women  are  subject 
to  the  disease.     Treatment  is  purely  symptomatic. 

Periarthritis. — Periarthritis  is  a  vague  term  under  which  it  is 
convenient  to  group  various  subacute  or  chronic  periarticular  con- 
ditions until  their  true  pathology  can  be  determined.  These  lesions 
seem  to  be  more  frequently  a  cause  for  complaint  around  the  shoulder 
than  elsewhere,  though  they  occur  sometimes  in  other  joints.  They 
usually  are  caused  primarily  by  trauma  (sprains,  subluxations,  etc.), 
and  are  maintained  either  by  static  strain  (especially  in  the  sacro- 
iliac joint),  or  frequently  recurring  trauma.  The  condition  w^as 
mentioned  at  p.  -08  and  385.  Codman  (190G)  has  drawn  attention 
to  the  subdeltoid  bursa  as  the  main  factor  in  such  disability;  while 
T.  T.  Thomas  (1911)  thinks  cicatricial  contraction  of  the  axillary 
portion  of  the  capsule,  resulting  from  sprain  or  self-reduced  sub- 
luxation, is  a  more  frequent,  if  not  the  only  cause  of  the  condition  at 
the  shoulder.  The  neighboring  nerves  (axillary  plexus,  sacral  plexus 
and  sciatic  nerve)  may  be  involved  in  periarticular  adhesions,  and 
thus  complicate  the  case. 

Symptoms. — The  symptoms  are  pain  and  disability,  and  in  the 
shoulder  especially  limitation  of  abduction  and  external  rotation. 
Tendinous  or  bursal  crackling  often  is  present.  "Sprain  fracture" 
of  the  greater  tuberosity  of  the  humerus  sometimes  exists.  Each 
case  requires  careful  individual  study  to  determine  the  original 
cause,  and  if  possible  the  pathological  lesion  present.  Suhdeltoid 
bursitis  is  characterized  by  tenderness  below  and  in  front  of  the 
acromion  when  the  arm  hangs  by  the  side,  this  tenderness  disappearing 
when  the  arm  is  abducted  and  the  bursa  disappears  beneath  the 
acromion;  in  chronic  cases  w'ith  adhesions  abduction  is  impossible, 
and  the  diagnosis  is  more  difficult,  but  usually  there  are  no  physical 
signs  in  the  axilla.  Implication  of  nerves  is  recognized  by  symptoms 
of  neuritis,  and  sometimes  trophic  changes  in  the  fingers.  ^Nly  own 
experience  leads  me  to  coincide  with  Thomas's  views,  that  in  most 
cases  the  main  lesions  are  in  the  axillary  region  of  the  joint,  and  not 
hi  the  subdeltoid  bursa, 

Treatment. — Massage,  pass'.ve  motion,  baking,  hot  air  douche, 
etc.;  ma\'  all  be  tried.    Improvement  is  slow,    In  resistant  cases  the 


ANKYLUSJS 


4«7 


patient  should  l)c  ctlicri/cd,  the  adlicsioiis  t'orcihly  ruptured,  and 
the  arm  dressed  in  aixhiction.  hnproxcnient  in  the  nutrition  of  the 
hand  may  t'oUow  sueii  treatment.  If  it  he  certain  that  tlie  snl)- 
(K'hoid  l)nrsa  is  the  seat  of  adhesions  wiiieh  eamiot  \)v  ruptured  hy 
manijiuhition,  tlie  hursa  may  he  opened  and  the  adhesions  cut  or  the 
hursa  exeisech  Dissection  may  reUeve  an  intractahh-  neuritis,  especially 
of  the  sciatic  ne^^■e. 

Ankylosis.  This  is  a  fixation  of  joints  hy  intra-articular  adhesions. 
Aeet)rdinii-  to  the  character  of  these  adhesions  ankylosis  is  classed 
■d»  fibrous  or  Ixnn/.  It  is  worth  while  to  repeat  here  again  that  limita- 
tion of  motion  from  extra-articnlar  causes  is  not  ankylosis;  it  has 
been  called  "false  ankylosis."  Thus  in  the  dystr()])hies  of  joints 
discussed  in  the  opening  i)aragraphs  of  this  chai)ter,  there  is  limitation 
of  motion,  hut  not  ankylosis.  True  anky- 
losis, whether  fibrous  or  bony,  probably 
always  is  the  result  of  infectious  arthritis 
or  of  trauma.  Complete  bony  ankylosis 
rarely  occurs  except  from  trauma,  most 
cases  of  bony  ankylosis  due  to  arthritis 
presenting  only  a  few  bands  or  processes 
of  bone  uniting  the  articulating  surfaces, 
the  remainder  of  the  joint  cavity  being 
filled  up  by  fibrous  adhesions.  If  only 
fibrous  ankylosis  is  present  it  usually  is 
possible  to  detect  a  few  degrees  of  motion 
if  the  joint  is  carefully  examined  under  an 
anesthetic. 

Treatment. — The  treatment  of  ankylosis 
in  tuberculous  artliritis  is  considered  at 
p.  487.  What  is  said  here  applies  to 
ankylosis  due  to  other  forms  of  infection 
(pyogenic,  pneumococcic,  typhoid,  etc.), 
or  to  trauma.  If  ankylosis  occurs  with  the 
limb  in  good  position,  no  treatment  may 
be  advisable,  especially  in  the  aged,  those 
with  visceral  disease,  etc.  A  stiff  hip  is 
largely  compensated  for  by  mobility  in  the 
lumbar  spine;  a  stiff  elbow,  if  the  hand  can 
be  brought  to  the  mouth,  may  be  useful  enough;  and  movements  of  the 
scapula  on  the  trunk  largely  compensate  for  ankylosis  in  the  scapulo- 
humeral joint;  but  almost  any  joint  which  is  in  bad  position  will  be 
improved  by  treatment.  With  very  few  exceptions,  however,  no  opera- 
tion should  be  undertaken  until  all  signs  of  active  disease  have  long 
since  subsided.  In  cases  of  fibrous  ankylosis,  where  the  disease  is  still 
subsiding,  the  use  of  weight  extension  or  of  elastic  compression 
against  a  splint,  or  of  a  splint  with  Stromeyer  screw  (Fig.  485),  may 
secure  improved  position;  and  in  cases  of  fibrous  ankylosis  and  false 
ankylosis  in  which  definitive  healing  has  occurred,  the  surgeon  may 


Fig.  485.  —  Brace  for  kuee 
with  Stromeyer  screw,  to  pro- 
duce gradual  extension.  Ortho- 
ptedic  Hospital. 


468 


DISEASES  OF  JOINTS 


make  attempts  to  secure  improved  position  by  rupture  of  adhesions 
under  an  anesthetic  {arthrolysis  or  brisement  force),  always  making 
movements  of  flexion  before  those  of  extension  (to  avoid  damage  to 
the  important  periarticular  structures  in  the  flexures  of  joints),  and 
seeking  to  rupture  adhesions  by  abrupt  movements  of  small  excursion 
rather  than  by  prolonged  or  violent  pressure.  The  joint  should  then 
be  immobilized  in  improved  position  until  inflammation  subsides,  when 
gentle  passive  movements  should  be  begun  and  active  use  encouraged. 
While  such  measures  often  secure  improved  position  and  sometimes 
a  moderate  range  of  motion  in  cases  of  false  or  flbrous  ankylosis, 
in  bony  ankylosis  open  operation  is  required. 


Fig.  486. — Instruments  used  in  excision  of  joints:  (1)  Blunt-pointed  resection  knife. 
(2)  Periosteal  elevator.  (3)  Guide  for  Gigli  wire  saw  (4),  and  (5)  handles.  (6)  Chain 
saw.     (7)   Butcher's  saw,  the  blade  of  which  can  be  reversed,  so  as  to  cut  upward. 

If  it  is  not  desired  to  restore  motion  to  the  joint,  simple  osteotomy 
may  suflflce  to  secure  good  position.  This  is  seldom  employed  except 
at  the  hip.  Here  the  neck  of  the  bone  may  be  divided  (Adams,  1871), 
but  as  this  often  is  distorted  by  disease,  subtrochanteric  osteotomy 
of  the  femur  (Gant,  1872),  is  preferable  (p.  487).     Excision  of  joints 


EXCISION  OF  JOINTS 


m) 


for  ankylosis  is  employed  to  eorrect  (leforinit\'  where  osteotomy  will 
not  snffice,  as  at  the  knee,  shoulder,  and  elbow.  In  the  latter  situa- 
tions a  movable  joint  is  soUf,dit,  hut  at  the  knee  the  object  of  excision 
is  to  secure  ankylosis  in  full  extension,  the  most  useful  position. 
Excision  of  the  knee  is  done  without  an  Esmarch  hand  by  a  transverse 
incision.  sli»j:htly  convex  downward,  across  the  front  of  the  joint  from 
the  j)osterior  eds>;e  of  the  base  of  one  condyle  to  that  of  the  other;  the 
skin  is  dissected  up  until  the  upper  border  of  the  patella  is  exposed 
and  the  quadriceps  tendon  is 
divided  at  its  insertion  into 
the  patella;  the  knee-joint  is 
acutely  flexed,  and  the  intra- 
articular ligaments  are  divided. 
The  condyles  of  the  femur 
being  thus  cleared,  the  saw 
is  applied  to  them  and  a  sec- 
tion about  half  an  inch  thick 
is  remov'ed,  not  at  right  angles 
to  the  long  axis  of  the  femur, 
but  obliquely  from  without 
inward,  from  before  backward, 
and  from  above  downward; 
in  other  words,  in  such  a 
manner  that  the  posterior 
internal  portion  of  the  sawn 
surface  shall  be  the  longest, 
and  the  anterior  external  the 
shortest.  The  tibial  condyles 
are  then  sawed  across  at  right 
angles  to  the  long  axis  of  the 
leg,  but  somewhat  bevelled 
antero-posteriorly  so  as  to 
correspond  to  the  section  of 
the  femur.  The  tibial  con- 
dyles with  the  attached  pa- 
tella are  then  removed  in  one 
mass  {Ashhurst's  operation, 
1884).  Barely  enough  of  the 
femur  and  tibia  are  removed 
to    allow   the  limb   to   come 

straight;  the  posterior  ligaments  always,  and  the  lateral  ligaments 
whenever  possible,  are  left  intact.  The  periarticular  tissues  are 
sutured  with  clironic  catgut,  and  the  skin  is  closed  with  provision 
for  drainage  for  twenty-four  hours.  The  limb  is  dressed  in  plaster 
of  Paris  and  immobilization  continued  for  six  or  ten  weeks  until 
union  is  firm.  If  complete  bony  ankylosis  (in  bad  position)  is  present 
already,  it  is  sufficient  to  excise  a  wedge  of  bone  to  restore  the  axis 
of  the  limb  (Figs.  487  and  488).     In  all  cases  of  excision  of  the  knee, 


Fig.  487. — Ankylosis  of  knee  in  flexion,  in  a 
girl  of  twelve  years;  result  of  arthrectomy  for 
tuberculosis  nine  years  previously.  (See  Fig. 
4S7.)     Episcopal  Hospital. 


470 


DISEASES  OF  JOINTS 


the  liml)  should  he  sui)iJ()rte(l  hy  a  hraee  for  a  year  afterwards.  The 
elhoic  is  excised  through  a  straight  posterior  iueision  spHtting  the 
triceps  muscle  near  the  inner  border  of  the  olecranon,  and  carefidly 
separating  its  tendinous  expansion  from  the  olecranon.  Injury  of  the 
ulnar  nerve  should  he  avoided;  it  is  most  liable  to  injury  just  below 
the  level  of  the  joint  close  to  the  inner  border  of  the  olecranon.  After 
the  lateral  ligaments  have  been  divided  the  joint  may  be  luxated. 
Enough  bone  is  removed  (leaving  the  radial  insertion  of  the  biceps) 

to  ensure  a  false  joint  being 
established;  a  space  of  at  least 
one  inch  and  a  half  should  ex- 
ist between  the  humerus  and 
bones  of  the  forearm,  to  ensure 
free  motion.  The  limb  is  im- 
mobilized only  until  the  soft 
parts  heal;  active  use  is  then 
encouraged.  Return  of  func- 
tion depends  largely  on  pre- 
servation of  the  periosteum 
into  which  the  triceps  inserts, 
and  its  fibrous  expansion  over 
the  radius.  The  shoulder  is 
excised  through  an  anterior 
incision  in  the  hollow  between 
the  coracoid  and  acromion  pro- 
cesses, thus  avoiding  injury  to 
the  branches  of  the  circumflex 
nerve.  The  long  tendon  of 
the  biceps  is  pushed  to  one 
side.  The  capsule  is  opened 
as  in  shoulder-joint  amputa- 
tions, and  the  muscles  inserted 
into  the  tuberosities  are 
divided  as  there  described. 
Usually  the  section  of  the 
humerus  is  made  through  the 
surgical  neck;  but  it  is  better 
to  remove  more  bone  from  the 
glenoid  than  from  the  humerus, 
since  restoration  of  function 
depends  largely  on  the  preservation  of  the  muscular  insertions  in  the 
latter.  After-treatment  is  the  same  as  in  excision  of  the  elbow.  In 
all  these  excisions,  it  is  well,  if  possible,  to  open  up  the  line  of  the  old 
articulation  first,  by  breaking  adhesions  and  sawing  across  bridges  of 
bone,  and  then  to  remo^•e  from  the  bone  ends  so  much  as  is  necessary. 
Attempts  to  excise  a  joint  in  one  block,  except  by  experienced  sur- 
geons, result  in  the  removal  of  too  much  or  too  little  bone.  Excision 
of  the  icrist  seldom  is  required;  in  most  cases  an  erasion  (p.  4<S(3)  suffices. 


Fig.  4bS. — Hesulr  of  cuneiform  resection  of 
the  knee  shown  in  Fig.  486.  The  epiphyseal 
lines  have  been  carefully  preserved.  Epis- 
copal Hospital. 


SPECIAL   ISFECTIOSS  OF   Till':  JOISTS  171 

11'  t'oniial  cxcisidii  is  doiic,  the  Ix'st  incision  is  that  oi  Alyiitcr  (l.S!)lj, 
splittini;-  the  ddrsmii  of  the  hand  hctwccn  the  index  and  middle 
finfi;('rs.     Ankylosis  is  the  desired   resnlt. 

Arfliropldsti/  is  an  operation  desi^nied  to  secure  a  niovai)le  joint 
with  the  niinininin  anioinit  of  hone  resection,  by  interposition  between 
the  bone  ends  of  pedieled  flaps  of  fat,  fascia,  or  muscle.  This  operation 
has  been  ])ractised  with  success  by  Murphy  (1904),  Ilu^uier  (100.")), 
G.  (i.  Davis  (H)()S),  and  others.  It  permits  the  formation  of  a  j^ood 
movable  joint  at  the  knee  if  the  lateral  and  patellar  iif^aments  are 
preserved  and  the  bone  ends  so  shaped  as  to  prevent  luxation; 
and  in  the  elbow  and  shoulder  it  preserves  the  free  motion  sectired 
l)y  the  ordinary  reseetion,  at  the  same  time  rendering  the  joint  more 
stable,  because  less  bone  has  to  be  removed.  But  the  operation 
is  difficult,  requires  special  training  and  experience  in  joint  surgery, 
and  is  not  always  successful.  Baer  (1909)  uses  pig's  bladder  instead 
of  autoplastic  flaps.  Lexer  (1908)  has  successfully  transplanted, 
from  ami)iitate(l  limbs,  entire  joints  with  their  attached  capsule 
and   ligaments. 

SPECIAL  INFECTIONS  OF  THE  JOINTS. 

The  special  infections  of  the  joints  usually  can  be  differentiated 
clinically  from  pyemic  infections,  and  from  each  other,  but  bacterio- 
logical study  of  the  joint  fluids  or  capsule  may  be  necessary.  Pyemic 
infections  of  joints  are  referred  to  at  p.  74. 

Pneumococcic  Infection  usually  is  a  complication  of  pneumonia 
(70  per  cent,  of  cases),  but  may  occur  from  other  sources,  especially 
otitis  media.  The  knee  and  shoulder  are  most  often  attacked.  There 
is  purulent  effusion,  and  the  signs  of  acute  arthritis  are  present. 
Treatment  consists  in  aspiration  of  the  fluid  and  injection  of  2  per  cent, 
formalin-glycerin  solution,  and  use  of  weight  extension.  Arthrotomy 
and  drainage  should  be  done  if  symptoms  are  severe  or  persist. 
The  mortality  is  about  33  per  cent.  (K.  Bulkley,  1914).  Ankylosis 
is  not  unusual,  but  formation  of  sinuses  is  rare. 

Gonococcic  Infection  usually  is  secondary  to  a  gonococcal  urethritis 
or  its  local  complications.  It  occurs  in  less  than  2  per  cent,  of 
cases,  and  mostly  in  the  male  sex;  almost  invariably  the  joint  con- 
dition appears  in  the  end  of  the  third  week  (eighteenth  to  twenty- 
second  day)  after  the  onset  of  gonorrhea.  The  polyarticular  form 
is  rheumatic  (i.  e.,  synovial)  in  character,  somewhat  resembling 
acute  rheumatic  arthritis;  but  the  monarticular  form  is  more  like  a 
septic  arthritis.  In  the  former  the  small  joints  of  the  hands  and  feet 
are  oftenest  affected;  sometimes  the  sterno-clavicular  joint.  In  the 
monartictilar,  form  the  knee,  ankle,  wrist,  and  elbow  are  oftenest 
invaded.  The  joints  become  extremely  painful,  swollen,  red,  and 
doughy  to  the  touch.  There  is  not  much  effusion.  Endocarditis 
is  an  occasional  complication.  Spontaneous  fistulization  is  rare. 
After  gonococcic  arthritis  the  joints  are  left  in  a  more  or  less  damaged 


472 


DISEASES  OF  JOINTS 


and   sometimes   seriously  deformed   state.     Bony   ankylosis   is   not 
unusual. 

Treatment. — If  rest  of  the  affected  joints  (the  patient  always  being 
confined  to  bed,  and  the  primary  infection  receiving  proper  attention) 
does  not  secure  marked  imi)rovement  within  forty-eight  hours,  the 
joints  should  be  opened,  and  irrigated  with  saline  or  formalin-glycerin 
solution,  and  closed  without  drainage.     There  is  too  little  effusion, 


Fig.  489. — Post-typhoid  ankylosis  of 
left  hip,  in  a  lad  of  sixteen  years. 
Dr.  Harte'scase.  (See  Fig.  490.)  Ortho- 
pedic Hospital. 


Fig.  490.  —  Result  of  subtrochanteric 
osteotomy  of  left  femur  for  bony  ankylosis 
in  bad  position.  (See  Fig.  489.)  Ortho- 
psedic  Hospital. 


as  a  rule,  for  mere  aspiration  and  injection  to  be  efficient.  Usually 
the  disease  is  much  shortened  by  joint  irrigation;  under  conservative 
measures  the  joints  may  remain  acutely  painful  for  weeks,  and  the 
patient's  health  often  is  gravely  affected,  hectic  fever  and  emaciation 
developing.  Vaccine  therapy  is  of  considerable  value.  Fuller  (1905) 
has  proposed  and  practised  drainage  or  extirpation  of  the  seminal 
vesicles  which  some  regard  as  the  focus  which  maintains  the  infection. 
Typhoid  Arthritis  occurs  during  or  after  convalescence  from  typhoid 
fever,  usually  about  the  third  or  fourth  week  of  the  disease.       Its 


UNKNOWN  INFECTIONS  OF  THE  JOINTS  473 

development  may  be  overlooked,  owing  to  the  patient's  apathetic 
state.  The  hip  is  most  often  alVected  (Figs.  4S!)  and  HIO) ;  su|)i)ura- 
tion  and  sinns  i'ormation  are  not  unusnal  (perhaps  from  mixed  infec- 
tion), thongh  as  in  pneumococcic  and  gonococcic  arthritis  ankylosis 
may  follow  without  frank  sujjpuration.  Pathological  luxation  may 
occur.  Ti/phoid  .s-pondi/litis  (p.  (ilo)  sometimes  is  seen,  though  a  true 
inflannnation  of  the  vertebral  joints  is  nnich  rarer  than  a  periarticular 
fibrosis. 

Subpyemic  and  Cryptogenous  Arthritis. — In  addition  to  these 
special  infections  of  joints,  and  to  tuberculous  and  syphilitic  joint 
diseases,  which  are  considered  at  p.  47(5  and  503,  there  are  a  number 
of  other  systemic  infections,  the  etiological  organisms  of  which  are  not 
known  in  all  cases,  but  which  sometimes  are  accompanied  or  followed 
by  inflammation  of  one  or  more  joints,  and  in  which  it  is  very  evident 
that  the  general  infection  is  responsible  for  the  local  inflammation, 
either  by  direct  action  of  its  bacteria,  or  through  the  toxins  derived 
from  these  microbes.  Such  articular  infections  may  be  grouped 
together  conveniently,  as  is  done  by  Marsh,  as  subpyemic  infections, 
some  of  them  having  a  more  or  less  evident  etiology  and  symp- 
tomatology (arthritis  and  scarlet  fever,  influenza,  dysentery,  etc.); 
w^hile  in  others,  such  as  "acute  articular  rheumatism,"  the  joint 
infection  itself  seems  almost  to  constitute  the  disease.  Acute  rheu- 
matic arthritis,  unless  some  efficacious  serum  or  vaccine  is  secured 
soon,  will  become  a  surgical  disease  when  physicians  become  thor- 
oughly convinced  that  it  is  a  form  of  pyemia.  Immediate  removal 
of  the  pharyngeal  tonsils,  thought  by  some  to  be  the  portal  of  infec- 
tion, has  been  adopted  in  a  few  cases.  Or  the  surgeon  may  open, 
irrigate,  and  close  the  first  joint  affected;  or  aspiration  and  injection 
with  formalin-glycerin  solution  (2  per  cent.)  may  be  done. 

Probably  the  form  of  metastatic  arthritis  most  often  encountered  is 
that  following  infections  of  the  pharynx,  naso-pharynx,  or  tonsils.  The 
joint  manifestations  occur  so  long  (several  weeks)  after  the  primary 
lesion  has  healed  that  their  inter-relation  usually  is  overlooked.  The 
patients  come  to  the  surgeon  with  bony  ankylosis,  and  tell  him  their 
physician  has  been  treating  them  for  rheumatism.  The  history  is 
that  very  soon  after  exposure  to  cold  or  wet,^  sudden  pain  developed 
in  one  or  more  joints;  probably  a  chill  occurred;  the  joint  became 
swollen,  red,  and  tender;  the  patients  lay  in  bed  a  long  time  in  one 
position;  and  finally  when  in  the  course  of  several  weeks  the  acute 
symptoms  subsided,  one  or  more  joints  were  found  to  be  stiff,  and 
have  remained  so  since.  A  skiagraph  will  show  bony  ankylosis. 
Now,  acute  rheumatic  artliritis  does  not  cause  ankylosis,  its  symptoms 
are  rapidly  relieved  by  salicylates,  and  the  disease  does  not  last  more 
than  two  or  three  weeks. 

These  acute  metastatic  joint  infections  should  be  treated  by  weight- 
extension  (to  prevent  deformity  and  if  possible  ankylosis),  by  aspira- 

^  This  is  to  be  regarded  merely  as  the  localizing  cause  of  the  joint  lesions.  The 
infection  which  occurred  two  or  three  weeks  previously  is  the  original  cause. 


474  DISEASES  OF  JOINTS 

turn  of  the  joint  contents  (to  relieve  pressure  on  the  synovial  mem- 
brane thus  preventing  its  destruction),  and  by  injection  of  10  to  15  c.c. 
of  a  2  per  cent,  formalin-glycerin  solidion  (to  sterilize  the  joint).  This 
injection  may  have  to  be  repeated  once  or  twice  after  intervals  of  a 
few  days  (Murphy,  1913). 

There  is,  moreover,  a  still  more  obscure  group  of  joint  diseases, 
which  clinically  give  every  evidence  of  being  infectious,  but  the 
true  pathogenesis  of  which  has  not  been  established  from  a  bacterio- 
logical stand-point.  These  may  be  called  cryptogenous  infections  of 
joints,  and  include  \arious  "rheumatoid"  conditions,  which  clinically 
resemble  infectious  as  distinguished  from  dystrophic  arthritis  (p.  452). 
Among  these,  chronic  rhemnatjc  arthritis,  a  disease  whose  existence 
I  do  not  doubt,  holds  an   important  place;  by  it  I  understand  the 


Fig.  491. — Chronic  rheumatic  arthritis;  age  fifr\-  \-(ar>;  had  acute  rheumatic 
arthritis  as  child  and  as  girl.     Orthoptedic  Hospital. 

damaged  condition  of  joints  which  may  persist  after  one  or  several 
attacks  of  "acute  articular  rheumatism;"  on  such  a  joint  may  be 
grafted,  as  on  to  any  joint  or  set  of  joints  whose  resistance  is  below 
par,  dystrophic  lesions.  I  believe  Fig.  491  represents  such  a  condition. 
Still's  Disease  (1897),  a  chronic  polyarticular  affection  of  young 
childhood,  resembling  atrophic  arthritis  in  many  respects,  and  accom- 
panied ])y  enlargement  of  the  lymph  nodes  and  spleen,  and  involve- 
ment of  the  cervical  spine,  probably  belongs  among  the  cryptogenous 
infections.  So  does  the  tuherculoiis  rheumatism  of  Poncet  (1903), 
which  is  a  subacute  polyarticular  infection,  somewhat  resembling  in 
onset  "acute  articular  rheumatism,"  but  probably  due  to  endogenous 
toxins  of  tubercle  bacilli  (Figs.  492  and  493).  In  this  group  of  crypt- 
ogenous infections  also  belong  certain  cases  of  arthritis  which  cease  to 


VNKXOWX    INFKCTIOXS   OF   TlIK   JOINTS  475 

tr()ul)k'  till"  palii'iit  wlii'ii  Uv  is  curod  t)t"  .sonic  source  ot"  inl'cctioii  which 
iiijiy  have  been  ncf!;lecte(l  for  yciirs;  such  are  dental  caries,  pyorriiea 


Fi(i.  492. — Tul)ciX'iilous  rhcuinatisni  in  a  girl  of  fi\-e  .\-e:us.  Acute  onset  in  left  ankle, 
some  weeks  after  an  attack  of  scarlatina.  Six  months  later  left  knee,  wrist,  and  shoulder 
liecame  similarly  affected;  reacted  to  tuberculin.  Photographed  one  year  after  onset. 
(See  Fig.  493.)   "  Orthopa;dic  Hospital. 


Fio.  493. — Patient  shown  in  Fig.   492,    one   year   later.    Normal    extension    in    left 
rist.     Knee  still  in  plaster  of  Paris,  and  four  years  later  not  yet  quiet.     Orthopsedic 

.•*„! 


wrist. 
Hospital. 

alveolaris;  sinus  diseases;  affections  of  the  tonsils;  empyema  thoracis 
(Fig.  494);  affections  of  the  lungs   (here   belongs  pidmonary  osteo- 


476 


DISEASES  OF  BONE 


arthropathy),  intestines,  appendix;  genito-iirinary  diseases  in  both 
sexes,  especially  chronic  semino-vesiculitis  or  prostatitis  in  the  male, 
and  cervical  lacerations  in  the  female,  etc.  Cases  of  joint  disease 
concerned  with  one  or  more  of  the  abo^■e  infections  are  constantly 
being  seen,  and  are  recognized  by  intelligent  physicians;  and  some 
remarkable  results  obtained  by  cure  of  the  primary  infection  have 
been  reported  by  Marsh,  Goldthwait,  and  others. 

In  chronic  rheumatoid   conditions  always   look   for   a   source  of 
infection. 


Fig.  494. — Pulmonary  osteoarthropathy.     Clubbed  fingers  four  years  after  operation 
for  empyema  (unhealed; .     Age  ten  years.     Children's  Hospital. 


Tuberculosis  of  Joints.' — Pathology. — In  tuberculous  arthritis  the 
primary  lesion  in  almost  all  cases,  especially  in  children,  is  in  the 
adjacent  bone,  and  the  synovial  membrane  lining  the  joint  cavity 
is  invaded  only  secondarily.  This  was  first  definitely  shown  by 
Nichols,  of  Boston,  in  1898.  The  bacilli  reach  the  bone  ends  through 
the  blood-stream,  presumably  from  a  preexisting  focus  in  the  bronchial 
or  mesenteric  lymph  nodes;  and  they  lodge  in  the  region  of  the  epiphy- 
seal cartilage  rather  than  in  the  diaphysis  of  the  bone  for  the  ana- 
tomical reasons  stated  at  p.  438.  The  di.sease  begins  on  one  side  or 
other  of  the  epiphyseal  cartilage.  An  additional,  and  perhaps  a  better 
reason  for  this  localization  of  the  bacilli  is  suggested  by  Ely  (1911): 
he  recalls  the  well  known  fact  that  tubercle  bacilli  flourish  where 
red  marrow  exists  (as  in  the  epiphyses  of  growing  bones),  whereas 
bone  which  contains  yellow  marrow  (adult  bones  throughout,  and 
the  diaphyses  of  juvenile  bones)  is  almo.st  immune  to  tuberculous 
invasion;  he  also  suggests  that  the  immunity  of  cartilage  and  fascia 
to  tuberculous  invasion  is  due  to  the  fact  that  only  in  connective 
tissues  which  have  epithelial,  epithelioid,  or  lymphoid  cells,  do  tubercle 
bacilli  find  a  suitable  soil  for  development,  and  that  in  this  way  the 
marked  affinity  of  tuberculosis  for  synovial  membrane  is  to  be  ex- 
plained. This  theory  of  Ely's  also  explains  why  primary  synovial 
tuberculosis  is  so  much  less  unusual  in  adults  than  in  children,  since 

^The  tuberculous  nature  of  these  diseases  was  first  clearly  demonstrated  by 
Volkmann,  in  a  classical  paper  published  in  1879. 


PATHOLOGY  OF   TUBERCULOUS  ARTHRITIS 


477 


the  hones  of  tlie  former  do  not  aiford  a  suitahle  soil  for  tlie  develop- 
ment of  tuberculosis,  owing  to  the  absence  of  red  marrow. 

In  tuberculosis  of  an  ei)iphysis  the  lesion  exists  in  th(!  marrow, 
the  cells  of  this  structure  being  grouped  around  the  invading  bacilli 
in  the  form  of  histological  tubercles;  the  bony  trabeculne  are  then 
destroyed,  the  centre  of  the  tuberculous  focus  undergoes  caseation, 
and  caries  of  the  bone  is  said  to  exist;  if  actual  liquefaction  occurs  a 
cold  absrcs's  of  bone  is  formed.  The  entire  bone  end  is  the  seat  of 
a  rarefying  osteitis,  the  bony  trabecuhe  be  ng  much  decreased  in 
size  and  strength,  while  the  marrow  spaces  are  increased.  Formation 
of  sequestra  is  rather  unusual ;  when  found  they  are  small,  and  tyi)ic- 
ally  worm-eaten  in  appearance.  Often  there  is  a  zone  of  sclerosed 
bone  immediately  around  the  sequestrum  or  the  central  caseous 
area,  while  outside  of  the  sclerotic  bone  the  rarefying  osteitis,  above 
described,  continues.  Caries  Sicca  is  a  term  used  by  Volkmann 
(1867)  to  describe  a  rare  form  of  joint  disease  now  recognized  as 
tuberculous,  which  is  seen  oftenest  in  the  shoulder  and  in  which 
gradual,  quiet,  fibrous  ankylosis  occurs,  without  swelling  or  other 
evidences  typical  of  tuberculous  arthritis. 

The  articular  cartilage  resists  for  a  long  time  invasion  by  the 
spreading  tuberculous  process,  and  when  the  joint  finally  is  entered 
it  is  more  often  at  the  site  of 
attachment  of  the  capsule  than 
in  the  centre  of  the  articular 
cartilage.  But  as  the  disease 
progresses  the  articular  cartilage 
is  gradually  covered  in  by  the 
tuberculous  granulation  tissue  or 
"pannus,"  and  is  perforated  in 
numerous  places,  giving  (Fig. 
495)  it  a  typical  sieve-like  (Volk- 
mann, 1882)  or  "pepper-pot"  ap- 
pearance; and  in  advanced  cases 
the  cartilage  may  be  entirely  de- 
stroyed. 

Before  actual  tuberculous  inva- 
sion of  the  joint  cavity,  there  may 
be  slight  serous  synovitis  with 
effusion,  from  irritation  due  to  the 
focus  in  the  neighboring  bone  end. 
When  the  synovia  has  once  been 

invaded,  or  in  the  rare  cases  of  primary  synovial  disease,  the  tuber- 
culous process  spreads  rapidly  throughout  the  joint,  attacking  and 
perhaps  destro}dng  the  ligaments,  reaching  out  along  adjacent  tendon 
sheaths  and  bursse,  and  causing  a  pulpy,  gelatinous  hyperplasia  of 
all  the  serous  tissues  attacked  (gelatinous  arthritis,  Ashhurst,  1871). 
Usually  there  is  very  little  eflfusion,  though  "tuberculous  hydrops" 
occasionally  occurs  (Fig.  496).    Either  by  condensation  of  fibrinous 


Fiu.  495. — Head  and  neck  of  femur 
excised  for  tuberculosis.  Note  "pepper- 
pot"  appearance  of  cartilage  covering  head 
of  femur;  pathological  fracture  of  neck:  and 
small  sequestrum  below.  Children's  Hos- 
pital. 


478 


DISEASES  OF  JOINTS 


flakes,  or  by  detachment  of  the  tips  of  the  villous  synovial  fringes, 
so-called  "rice-bodies"  or  "melon-seed  bodies"  may  develop  in  tuber- 
culous joints.  By  most  authorities  these  are  regarded  as  highly 
characteristic  of  the  tuberculous  nature  of  the  joint  lesions:  tubercle 
bacilli  frequently  have  been  found  within  the  rice-bodies,  and  their 
inoculation  into  susceptible  animals  causes  generalized  tuberculosis. 

If  the  tuberculous  process  extends  to  the  skin  surface,  and  a  cold 
abscess  of  bone  discharges  itself  through  a  sinus,  secondary  infection 

with  pyogenic  cocci  is  extremely  apt  to 
occur.  Before  such  seconrlary  invasion 
the  walls  of  a  sinus  communicating  with 
a  tuberculous  focus  are  not  themselves 
the  seat  of  tuberculosis;  but  when  sec- 
ondary infection  is  present  the  connec- 
tive tissue  which  forms  the  walls  of 
such  a  sinus  are  studded  with  tubercles 
(Ely,  1911).  Secondary  invasion  with 
pyogenic  cocci  may  occur  through  the 
blood-stream  before  any  sinus  forms; 
such  a  complication  is  apt  to  hasten  the 
disintegrating  process  and  encourage 
formation  of  sinuses. 

Healing  occurs  by  the  encapsulation  of 
the  tu})erculous  focus  or  its  replacement 
i)y  fibrous  tissue.  If  the  joint  cavity 
has  been  invaded  this  implies  more  or 
less  firm  fibrous  ankylosis.  In  most 
cases  the  tuberculous  process  merely 
becomes  latent,  and  is  prone  to  become 
active  again  if  the  joint  is  subjected  to 
unusual  strain,  or  if  the  general  health 
becomes  impaired,  particularly  })y  the 
development  of  pulmonary  tuberculosis. 
Clinical  Course  and  Symptoms. — Joint  tuberculosis  is  much  more 
frequent  in  children  than  in  adults,  arising  especially  during  the 
first  decade  of  life.  The  spinal  joints  are  those  most  often  affected; 
the  knee  and  hip  come  next  in  order  of  frequency;  while  the  joints 
of  the  i^ot,  elbow,  and  wrist  are  more  frequently  diseased  than  the 
shoulder.  In  about  one-third  of  the  ca.ses  in  children  a  history  of 
traumatism  can  be  obtained,  two  or  three  weeks  previous  to  the 
onset  of  joint  symptoms;  and  this  generally  is  regarded  as  having  a 
distinct  etiological  relation  to  the  development  of  the  disease.  But 
it  mu.st  be  remembered  that  nearly  all  children  sustain  slight  joint 
injuries,  yet  comparatively  few  develop  tuberculous  arthritis;  so 
that  it  is  necessary  to  assume  a  predisposition  to  tuberculosis  and 
the  existence  of  a  primary  focus  elsewhere  in  the  body.  The  injury 
which  precedes  the  tuberculous  joint  symptoms  rarely  is  severe; 
fractures  scarcely  ever  are  followed  by  tuberculosis,  and  fractures 


rc-iilotis  h\-drop.s 


Fk;.  49G.— Till; 
of  right  knee.  Age  eight  year.s. 
Duration  six  months.  For  persist- 
ence of  .symptoms,  excision  of  knee 
was  done  five  years  later.  (Dr. 
Dickson's  case.)  OrthopEedic 
Hospital. 


SYMI'TOMS   OF    TLHKRCVLOVS   AinHRITIS  479 

in  tlu'  tuhiTculous  heal  normally.  Two  exjjlanations  are  t)flVrc(l  for 
this:  one  is  that  the  more  severe  injury  arouses  better  defensive 
action  on  the  part  of  the  patient ;  the  other  is  that  sexcre  lesions  recjuire 
careful  and  i)rolonji-c(l  treatment,  and  healinj;,  therefore,  is  more  ai)t 
to  oceur  than  after  a  trivial  injury  which  often  is  nejijlected. 

Amonj;  the  earliest  subjective  symptoms  of  tuberculous  arthritis 
are  disability  and  pain.  The  joint  is  used  less,  the  joint  is  "favored," 
and  it  fjives  evidence  of  bein^  more  easily  tired  than  the  normal 
joint.  StilVness  ])resent  on  getting  out  of  bed  in  the  morning  may 
wear  away  during  the  day;  but  toward  evening  the  joint  again 
becomes  disabled,  and  this  is  evidenced  by  slight  limp,  and  com])laints 
of  pain.  Pain  may  be  almost  absent  except  when  the  joint  is  used; 
but  frequently  a  joint  which  is  painless  when  the  child  is  awake  will 
trouble  it  at  night,  causing  restlessness,  and  on  falling  asleep  and 
relaxing  its  muscles  the  child  will  experience  "starting  ])ains"  which 
will  rouse  it  momentarily  from  sleep  with  a  "night-cry."  Instead 
of  pain  being  felt  at  the  diseased  joint,  it  may  be  referred  to  the 
peripheral  distribution  of  the  nerve  supplying  the  joint:  thus  in 
tuberculous  spondylitis  pain  frequently  is  present  in  the  epigastrium 
(intercostal  nerves),  and  in  tuberculosis  of  the  hip  pain  is  referred 
to  the  knee  (obturator  nerve). 

Examination  of  the  diseased  joint  at  this  early  stage  shows  slight 
but  persistent  muscular  spasm.  The  muscles  surrounding  a  joint 
are  supplied  by  the  same  nerve  that  supplies  the  joint,  and  irritation 
of  the  joint  causes  reflex  irritation  of  the  adjacent  muscles  (Hilton's 
law,  1877).  The  joint  may  be  held  absolutely  rigid  by  the  patient, 
but  in  the  earliest  stages  the  most  that  can  be  detected  is  limitation 
of  motion  in  all  directions:  there  is  neither  full  extension,  flexion, 
abduction,  adduction,  nor  rotation;  and  forcing  any  of  these  motions 
causes  pain.  Comparison  with  movements  of  the  corresponding 
unaffected  joint  is  imperative.  The  joint  is  held  in  the  most  com- 
fortable position  and  is  consistently  protected  by  the  patient:  a 
sore  wrist  or  elbow  is  supported  by  the  other  hand,  and  if  the  hip  or 
knee  is  involved  the  sound  foot  may  be  put  under  the  ankle  of  the 
diseased  limb  and  be  used  as  a  splint  to  prevent  motion  in  the  painful 
joint. 

There  is  tenderness  to  palpation  directly  over  the  joint,  and  per- 
sistent tenderness  of  a  bone  end  with  evidences  of  articular  irritation 
is  a  valuable  sign,  l^nless  the  disease  is  advanced,  or  primarily 
synovial  in  origin,  there  is  rarely  much  thickening  of  the  capsule  or 
synovial  effusion.  In  superficial  joints  (knee,  elbow,  ankle)  more 
or  less  heat  usually  is  appreciable,  but  in  the  hip  this  seldom  can  })e 
detected.  ^Muscular  atrophy,  an  evidence  of  disuse,  is  a  valuable 
confirmatory  sign  of  tuberculous  arthritis;  in  early  stages  it  sometimes 
can  be  detected  only  by  measurement,  but  in  later  stages,  where 
articular  thickening  is  present  and  accentuates  the  atrophy,  it  is 
apparent  at  a  glance  (Fig.  523). 

With  these  local  signs  there  is  seldom  much  constitutional  reaction. 


480  DISEASES  OF  JOINTS 

The  temperature  may  be  raised  1°  or  2°  in  the  evening,  and  loss  of 
appetite  and  malaise  may  be  present;  but  there  is  no  acute  inflamma- 
tory state  such  as  is  seen  in  cases  of  septic  arthritis. 

As  the  disease  progresses,  the  joint  thickening  increases,  being  of  a 
doughy,  boggy  consistency,  and  t\-pically  spindle-shaped  in  outline. 
The  skin  is  pallid,  and  the  affection  well  deserves  the  name  "white 
swelling"  which  has  been  applied  to  it  for  so  many  years.  Spastic 
contraction  of  the  surrounding  muscles  passes  into  true  contractures, 
which  will  maintain  deformity  even  if  ankylosis  is  absent.  Progres- 
sive joint  disintegration  may  lead  to  partial  or  complete  dislocation; 
and  this  usually  is  attended  by  relief  from  pain.  Finally,  by  rupture 
of  cold  abscesses,  sinuses  may  develop,  and  usually  this  complication 
is  quickly  followed  by  secondary  infection,  resulting  in  hectic  fever, 
and  the  gradual  but  progressive  decline  of  the  patient's  general 
health. 

Diagnosis. — Symptoms  of  subacute  arthritis  in  a  child,  from  no 
apparent  cause,  or  following  slight  injury,  and  without  marked 
constitutional  reaction,  but  persisting  in  spite  of  temporary  rest, 
always  should  excite  a  suspicion  of  tuberculosis.  This  suspicion  is 
strengthened  by  a  family  history  of  tuberculosis,  either  pulmonary 
or  osseous,  and  is  made  nearly  positive  if  there  is  persistent  elevation 
of  temperature  of  1°  or  2°,  if  the  tuberculin  tests  (p.  SI)  are  posi- 
tive, and  if  there  is  no  leukocj-tosis.  Skiagraphic  examination  rarely 
will  reveal  any  bony  focus  so  early  in  the  disease  as  to  be  of  much 
value  in  doubtful  cases,  but  a  squaring  of  the  epiphyses,  particularly 
at  the  knee,  is  regarded  as  characteristic  of  tuberculosis. 

A  sprain  will  cease  to  cause  acute  symptoms  if  the  joint  is  put  to 
rest  for  two  or  three  weeks;  but  a  tuberculous  arthritis  always  will 
be  roused  to  activity  if  joint  function  is  resumed  in  so  short  a  time. 
A  septic  arthritis  is  more  violent  in  its  onset,  is  attended  by  much 
more  constitutional  disturbance,  and  progresses  to  early  suppuration 
and  joint  disintegration;  its  course  is  run  in  days  and  weeks,  while 
that  of  a  tuberculous  arthritis  extends  over  months  and  years.  Acute 
rheumatic  arthritis  is  in  most  cases  a  polyarticular  affection,  is  char- 
acterized by  high  temperature,  cardiac  or  pleural  complications, 
h;v'perleukocytosis,  and  marked  local  inflammatory  reaction.  It  is 
rare  in  young  children.  In  syphilitic  arthritis  other  signs  of  syphilis 
nearly  always  can  be  detected. 

A  positive  diagnosis  of  tuberculosis  always  can  be  made  if  tubercle 
bacilli  can  be  found  in  the  synovial  membrane,  rice-bodies,  joint- 
fluid,  etc.,  or  if  inoculation  with  these  substances  causes  tuberculosis 
in  a  susceptible  animal. 

Prognosis. — The  most  favorable  cases  are  those  of  apparent  osseous 
origin  in  children,  in  which  efficient  treatment  is  instituted  before 
evidences  of  invasion  of  the  synovia  are  demonstrable,  and  in  which 
the  symptoms  are  so  slight  as  scarcely  to  warrant  a  positive  diagnosis. 
These  are  the  cases  in  which  patients  recover  with  joints  which  are 
to  all  intents  and  purposes  normal.     After  joint  invasion  is  once 


TREATMENT  OF   TUBERCULOUS  ARTHRITIS  481 

tlc'iiioiistrahle,  and  in  cases  primarily  synovial,  the  most  that  can  be 
hoped  for  is  recovery  with  more  or  less  impairment  of  motion;  and 
the  more  firm  the  ankylosis  the  less  apt  will  the  ])atient  be  to  have 
recurrence  of  the  disease.  After  secondary  infection  the  prof;;nosis 
is  t^loomier  both  as  to  function  and  life;  and  in  adults  all  forms  of 
tuberculous  arthritis  are  much  more  serious  than  in  children.  In 
general  terms  it  may  be  stated  that  from  one-third  to  one-half  of 
j)atients  with  tuberculous  arthritis  die  as  a  result  of  their  joint  lesions; 
few  indeed  as  a  direct  consequence  (then  mostly  from  hectic,  amyloid 
degeneration  of  the  viscera,  etc.),  but  many  from  tuberculous  menin- 
gitis, phthisis,  or  some  intercurrent  malady  from  which  healthier 
persons  would  have  recovered.  In  cases  ending  in  apparent  recovery, 
which  often  is  merely  latency  of  the  tuberculous  process,  the  course 
of  treatment  must  last  from  one  to  five  years  or  longer;  and  other 
patients  must  continue  treatment  until  death  removes  them  from 
the  surgeon's  care. 

Treatment. — The  coiistitutional  treatment  of  surgical  tuberculosis 
was  discussed  at  p.  82;  its  value  in  tuberculous  arthritis  is  inesti- 
mable, and  never  should  be  forgotten.  The  most  efficient  local  treat- 
ment frequently  is  powerless  to  check  the  disease;  and  sometimes 
constitutional  treatment  alone  is  able  to  restore  a  patient  to  health. 
The  surgeon  must  not  overlook  the  fact  that  it  is  better  to  have  a 
healthy  body  with  a  stiff  or  deformed  joint,  than  to  have  a  straight 
and  comely  joint  without  a  body  capable  of  sustaining  life.  If  the 
general  health  is  good,  joint  function  can  be  restored  subsequently 
by  an  orthopedic  operation.  Every  hospital  should  have  an  open 
air  ward  or  at  least  a  porch  available  for  tuberculous  joint  cases, 
where  the  advantages  of  constitutional  and  local  treatment  may  be 
combined  for  those  most  requiring  such  care. 

Local  treatment  may  be  summed  up  almost  in  one  word:  Rest. 
It  is  not  known  definitely  how  this  acts,  but  a  plausible  theory  is 
suggested  by  Ely  (1911):  he  contends  that  cure  is  effected  by  abolish- 
ing joint  function,  because  thus  both  red  marrow  and  synovia  become 
atrophic  and  in  the  case  of  ankylosis  entirely  disappear;  and  where 
they  are  not,  tubercle  bacilli  cannot  exist. 

There  are  two  chief  methods  by  which  joint  rest  is  obtained: 
fixation  and  traction.  Fixation  is  secured  by  the  use  of  splints,  plaster 
cases,  braces,  etc.,  the  sole  object  being  to  abolish  motion  at  the 
diseased  joint  as  effectually  as  possible;  this  not  only  relieves  pain, 
but  has  direct  influence  in  checking  the  tuberculous  process.  By 
traction  is  understood  not  so  much  actual  extension  on  the  limb 
sufficient  to  pull  the  joint  surfaces  apart,  as  cessation  of  weight- 
bearing  and  relief  of  pressure:  it  acts  by  relieving  pain  and  securing 
rest,  but  also  prevents  deformity  which  is  prone  to  occur  when  the 
weight  of  the  bod}'  is  borne  on  the  softened  bone  ends.  Traction 
is  applied  chiefly  to  the  knee,  hip,  and  spine;  fixation  alone  usually 
is  sufficient  for  the  upper  extremity. 

Whenever  possible  in  the  spine  and  lower  extremity  the  advantages 
31 


482 


DISEASES  OF  JOINTS 


of  fixation  and  traction  should  be  combined.  This  is  best  accomplished 
by  bed-treatment,  so  long  as  acute  symptoms  persist,  regardless  of 
the  stage  of  the  disease.     Recumbency  at  once  removes  the  weight 


Fig.  497. — Bradford  frame.     See  text. 


of  the  body  from  the  diseased  joints,  and  fixation  is  much  more  readily 
secured.  In  children,  the  use  of  a  Bradford  frame  (1890)  (Fig.  497) 
to  which  the  body  is  strapped,  provides  fixation  for  spine,  hip,  or 


Fig.  498. — On  the  roof  garden  of  the  Orthoptedic  Hospital.    Showing  Bradford 
frames  with  head  and  foot  extension. 


knee,  in  the  most  efficient  manner.  This  frame  is  made  of  gas-pipe, 
and  is  covered  with  tightly  stretched  canvas;  it  should  be  a  little 
longer  than  the  patient  and  as  wide  as  from  one  armpit  to  the  other. 
The  child  is  fastened  to  it  by  a  broad  canvas  apron  covering  chest 


TREATMENT  OF   Tl' liERCULOUS  ARTIllilTlS  483 

and  alxloiiuMi,  or  hy  straps  crossing  tlu'  slionldcrs.'  Tho  franir  thns 
hecomi's  a  |)art  of  the  child,  and  the  two  together  can  hv  carried  al)o\it 
from  room  to  room,  or  from  ward  to  roof  garden  (Fig.  4!)N),  thns 
preventing  the  painfnl  and  harmfnl  joint-movements  necessitated 
hy  carrying  the  child  in  the  arms  or  transferring  it  to  a  stretdier 
and  hack  again  to  the  bed.  Weight-extension  nsually  is  a  desiral)Ie 
adjnxant  in  secnring  joint  fixation,  and  is  the  most  effectnal  method 
of  ()\(Tcoming  pain  and  nuiscnhir  sj)asm,  to  which  hitter  factor 
deformity  in  tiie  earliest  stages  is  (hie.  Weight-extension  always  should 
be  applied  in  the  axis  of  the  deformity  (Fig.  512),  and  as  spasm 
lessens  the  direction  of  the  extension  can  })e  gradually  changed  until 
the  normal  ])osition  is  secured.  (Ireat  care  must  he  exercised  during 
recumhent  treatment  to  keep  the  foot  at  a  right  angle  with  the  leg, 
preventing  the  development  of  talipes  equimis. 

When  all  symptoms  of  arthritis  (limitation  of  motion  from  si)asm, 
l^ain,  fever,  etc.)  have  been  absent  for  a  month  or  more,  recumbent 
treatment  may  be  discontimied.  This  stage  is  reached  after  two 
to  six  months  in  cases  coming  under  observation  in  the  early  stages 
of  the  disease.  Tf  local  treatment  (fixation  and  traction)  are  now 
recklessly  discontimied  in  the  erroneous  idea  that  the  joint  is  cured, 
and  if  the  patient  is  allowed  to  resume  joint  function,  it  will  be  only 
a  few  weeks  before  all  symptoms  of  arthritis  return,  and  possibly  in 
aggravated  form.  It  is  absolutely  imperative  to  guard  the  joint 
against  injury  and  strain  by  continuing  for  a  long  period  fixation  or 
traction,  or  })otli,  during  ambulatory  treatment.  By  the  use  of 
plaster  of  Paris  cases,  braces,  crutches,  etc.,  both  fixation  and  traction 
(in  modified  forms)  can  be  continued;  and  this  should  be  done  until, 
by  allowing  gradual  return  of  function  (first  limited  motion,  then 
weight-bearing),  the  surgeon  proves  that  the  joint  lesion  has  become 
.so  thoroughly  encapsulated  as  not  to  be  liable  to  cause  recrudescence 
of  the  disease.  This  period  of  ambulatory  after-treatment  extends 
always  through  several  months,  usually  through  a  year  or  more,  and 
often  for  many  years.  Only  by  making  haste  slowly  can  permanent 
good  results  be  achieved.  If  there  is  any  reason  (there  are  few  good 
reasons)  why  recumbent  treatment  is  impossible  when  the  patient 
first  is  seen,  ambulatory  treatment  with  fixation  and  traction  may  be 
employed  from  the  start;  but  this  is  apt  to  promote  ankylosis,  and 
deformity  is  very  difficult  to  prevent.  ^loreover,  in  many  cases  the 
symptoms  are  so  acute  that  rest  in  bed  is  an  absolute  necessity. 
Yet  I  believe  with  Coudray  (1911),  that  in  no  case  should  a  manifest 
tendency  toward  ankylosis  be  hindered;  the  joint  should  be  kept  in 
good  position,  but  attempts  to  preser^'e  motion  are  extremely  apt 
to  keep  the  disease  active.  The  surest  and  most  lasting  cures  are 
those  which  follow  ankylosis. 

Treatment  of  Cold  Abscesses. — If  the  joint  be  put  at  rest,  and  the 
patient  kept  in  the  open  air,  the  threatening  abscess  may  cease  to 

^  G.  G.  Davis  uses  also  an  uppei-  frame,  well  padded  and  moulded  to  the  body, 
to  hold  the  child  against  the  lower  frame. 


484  DISEASES  OF  JOINTS 

enlarge,  and  in  not  a  few  cases  gradually  will  disappear.  Hence 
these  conservative  measures  should  be  given  full  trial.  If  the  abscess 
continues  to  enlarge,  and  threatens  to  approach  the  skin,  with  the 
consequent  danger  of  infection  from  the  skin  cocci,  even  before 
spontaneous  rupture  makes  such  an  infection  sure,  I  think  it  is  best 
to  expose  the  abscess  wall  by  careful  dissection  tlirough  overlying 
healthy  tissues,  to  incise  the  abscess,  evacuate  its  contents,  and  wipe 
the  abscess  cavity  gently  but  thoroughly  with  iodoform  gauze.  I 
cannot  see  that  anything  is  to  be  gained  by  curetting  the  walls  of  the 
abscess  cavity,  nor  by  attempts  to  "excise  the  sac,"  which  in  many 
cases  is  an  impossibility.  The  incision  to  reach  the  abscess  is  sutured 
in  layers,  without  drainage.  Children  should  be  etherized,  but  in 
adults,  local  anesthesia  is  sufficient.  In  most  cases  (fifty-one  out  of 
sixty,  according  to  Starr,  1907),  the  incision  heals  without  breaking 
down  at  any  point,  and  in  only  a  very  few  cases  does  the  abscess  refill 
and  require  a  second  evacuation.  It  is  dangerous  to  leave  a  cold 
abscess  to  itself  until  the  overlying  skin  has  become  adherent  and 
reddened,  since  secondary  infection  from  skin  cocci  is  frequent,  and 
rapid  joint  disintegration,  hectic,  amyloid  disease,  etc.,  follow;  and 
it  is  still  more  dangerous  to  open  a  cold  abscess  without  perfectly 
aseptic  technique,  or  to  drain  it  by  tube  or  gauze  after  incision,  or 
to  allow  it  to  discharge  itself  spontaneously.  But  sometimes  the 
patient  is  not  seen  until  spontaneous  rupture  threatens,  and  secondary 
infection  already  is  present.  Under  such  circumstances  the  abscess 
should  be  evacuated  by  a  small  incision  where  it  is  pointing,  but 
should  not  be  drained ;  the  puncture  should  be  occluded  with  aseptic 
gauze,  and  in  many  cases  little  or  no  subsequent  discharge  will  occur, 
the  "hot"  will  gradually  resume  its  character  of  "cold"  abscess, 
and  eventually  may  be  absorbed.  Thus  the  formation  of  sinuses  and 
prolonged  suppuration  may  be  prevented. 

Aspiration  of  a  cold  abscess  is  inferior  to  formal  incision,  because 
it  cannot  be  done  satisfactorily  until  the  ])ii-  i>  very  close  to  the 
surface  and  unless  it  is  very  fluid.  A  certain  iiiuiilx.T  of  cures,  however, 
will  follow  aspiration  and  injection  of  a  10  per  cent,  iodoform-glycerin 
emulsion. 

Treatment  of  Sinuses. — In  tuberculous  arthritis  sinuses  nearly 
invariably  are  an  indication  of  secondary  infection:  if  no  secondary 
infection  is  present  (a  fact  which  bacteriological  investigation  will 
demonstrate),  they  usually  will  heal  under  rest  and  constitutional 
treatment.  I  have  had  exceptionally  good  results  from  helio- 
therapy: the  sinuses  are  exposed  to  direct  sunlight,  beginning  with 
periods  of  five  minutes  twice  daily,  and  increasing  the  length  of  the 
exposures  as  rapidly  as  possible  without  producing  sunburn.  If 
the  sinuses  fail  to  heal,  and  if  discharge  of  pus  is  not  profuse,  they 
should  be  filled  with  the  bismuth  paste  of  Beck  (1905):  one  part  of 
bismuth  subnitrate  (arsenic  free)  to  two  parts  of  sterile  amber  vaselin. 
This  is  heated  in  a  water  bath  until  fluid,  and  is  injected  into  the 
sinuses  by  a  syringe  which  after  being  boiled,  is  rinsed  in  alcohol  and 


TREATMENT  OF   TUBERCULOUS   ARTHRITIS 


4S5 


;ill()\v(>(l  to  (Irv  before  it  is  filled  with  the  li(iui(l  paste.  The  sinuses 
;ire  filled  as  full  as  i)(>ssil)le.  A  skiaj,Tai)li,  made  after  distending  the 
sinuses  with  this  paste,  will  show  their  ori.uiu  and  raniifieations  (Fig. 
499).    If  pus  should  he  dammed  uj)  hehind  the  i)ast(>.  the  iuereased 


Fig  499  —Skiagraph  of  tubertulous  arthritis  of  left  hip,  with  sinus  discharging  on 
outer  surface  of  thigh;  sinus  has  been  distended  with  Beck's  bismuth  paste.  Boy  aged 
ten  years-  coxalgia  for  six  years.  Abscess  punctured  three  months  before  skiagraph  was 
made,  because  it  was  pointing  and  because  there  was  secondary  infection  from  skin 
cocci.     Orthopaedic  Hospital. 

local  heat  will  cause  the  paste  to  melt,  and  it  will  be  extruded  from 
the  sinus  spontaneously.  The  mode  of  action  of  bismuth  paste  is 
not  certainly  known,  but  it  causes  marked  improvement,  the  dis- 
charge diminishing  and  the  sinuses  often  closing  in  a  comparatively 
short  time.    If  a  firmer  injection  mass  is  desired,  the  following  formula 


486  DISEASES  OF  JOINTS 

(Beck's  paste  No.  II)  may  be  employed:  Bismuth  subnitrate  (arsenic 
free),  30  parts;  amber  vaseliii,  50  parts;  paraffin,  10  parts.  Or  Mosetig- 
Moorhof's  iodoform  })one-wax  may  be  used  (p.  435).  Bismuth 
poisoning  has  been  observed  in  a  few  instances,  so  not  more  than 
four  or  six  oimces  of  Beck's  paste  should  be  employed  in  a  child. 

If  profuse  suppuration  persists  in  spite  of  conservative  measures, 
it  is  probable  that  a  sequestrum  is  present,  and  this  may  be  removed 
by  curette  or  gouge.  Formal  operation  in  children  rarely  is  advisable. 
Injections  of  alcoholic  solutions  of  iodin  (2  to  10  per  cent.)  are  useful 
in  overcoming  secondary  infection. 

Operative  Treatment  in  Tuberculous  Arthritis. — It  might  be  thought 
that  early  excision  of  the  diseased  area  would  abort  the  disease,  but 
unfortunately  it  scarcely  ever  is  possible  to  locate  by  skiagraphy 
or  otherwise  an  extra-articular  focus;  nor  would  what  might  be  con- 
sidered total  extirpation  of  the  focus  amount  to  much  more  than 
removal  of  the  centre  of  an  area  infected  far  beyond  what  is  indicated 
by  gross  appearances.  When  once  the  joint  itself  is  involved,  only  a 
formal  excision  could  remove  all  the  disease,  and  in  children  such  an 
operation,  which  implies  removal  of  the  epiphyses,  is  productive  of 
such  marked  deformity  and  disability  as  to  be  generally  condemned 
by  intelligent  surgeons.  Moreover,  in  children,  the  results  of  con- 
servative treatment  thoroughly  carried  out,  as  outlined  above,  are 
so  satisfactory,  that  operation  presents  no  advantages  in  the  early 
stag&s  of  the  disease.  In  adults,  on  the  other  hand,  the  results  of 
conservative  treatment  have  proved  so  disheartening,  chiefly  through 
their  inability  to  endure  confinement  to  bed,  and  their  tendency 
to  develop  phthisis,  that  joint  excision  or  even  amputation  is  the 
accepted  form  of  treatment.  Ely  (1911)  claims  that  an  excision  which 
will  produce  ankylosis  and  thus  permanently  abolish  joint  function 
is  all  that  is  necessary  to  effect  a  cure;  he  asserts  that  it  matters  not 
how  little  bone  is  removed,  nor  how  much  tuberculous  material  is 
left,  so  long  as  ankylosis  is  obtained,  as  this  in  itself  will  cause  dis- 
appearance of  synovia,  which  is  the  joint  tissue  on  which  in  adults 
tubercle  bacilli  almost  solely  subsist.  But  hitherto  it  has  been  the  habit 
of  surgeons  to  remove  as  much  diseased  tissue  as  possible.  In  chil- 
dren, excisions,  if  done,  should  be  limited  to  the  epiphyses  of  the 
bones,  the  epiphyseal  cartilages  being  rigorously  respected,  and  any 
focus  in  the  metaphysis  should  be  evacuated  by  the  curette  through 
a  perforation  of  the  epiphyseal  cartilage,  and  not  by  sawing  off  the 
bone  end  until  all  diseased  tissue  disappears.  Arthredomy  or  erasion 
of  joints,  adapted  especially  to  the  knee,  was  introduced  by  Wright, 
of  Manchester  (1881),  and  in  this  country  by  J.  Ashhurst,  Jr.  (1889), 
as  a  substitute  for  excision  in  children;  it  aims  to  remove  all  the  diseased 
soft  tissues  (synovia,  ligaments,  cartilages)  without  invading  the 
bones;  and  may  be  employed  for  the  purpose  of  effecting  ankylosis 
when  conservative  measures  fail  to  secure  subsidence  of  symptomis. 
Like  excision,  there  is  nothing  specific  in  its  action;  it  is  merely  a 
method  of  joint  disinfection. 


THE  ATM  EST  OF   TLBEliCV  LOl'S   AMOIJJSJS 


487 


Trcaiinenf  of  Anki/losis  from  Tiihrmilon.s-  Arllirifl.s.-  \s  lias  already 
been  indicated,  ankylosis  t'ollowiiif;  tuherculous  arthritis  often  inii)lies 
merely  a  latency  of  the  disease,  though  no  doubt  definitive  cure 
sometimes  occurs.  But  owing  to  the  frequency  with  which  slight 
trauma,  even  many  years  after  ankylosis  has  occurred,  may  rouse 
the  dormant  lesion  into  activity,  the  surgeon  should  be  extremely 
cautious  in  efforts  to  restore  joint  motion.  If  ankylosis  has  occurred 
in  good  position,  especially  in  the  joints  of  the  lower  extremity,  no 


Fig.  .jOO. — Ankylosis  of  hip  from  old 
coxalgia,  age  thirteen  years.  Ortho- 
paedic Hospital. 


Fig.  501. — Same  patient  as  Fig.  500; 
one  year  after  subtrochanteric  osteotomy 
of  femur.    Orthopsedic  Hospital. 


treatment  should  be  adopted,  as  a  rule.  For  deformity  at  the  hip, 
subtrochanteric  osteotomy  (p.  468)  is  the  best  treatment,  as  it  divides 
the  bone  where  healthy  (just  below  the  lesser  trochanter),  and  there 
is  very  little  risk  of  rousing  the  old  disease,  especially  if  the  bone 
section  is  made  with  a  saw  instead  of  by  osteotome  and  mallet.  A 
puncture  is  made  about  two  inches  below  the  great  trochanter,  on 
the  outer  side  of  the  femur,  with  Adams's  knife;  this  is  passed 
directly  to  the  bone,  and  is  then  carried  across  its  anterior  surface, 
and  along  this  knife  as  a  guide,  Adams's  saw  is  passed;  the  knife 


488 


DISEASES  OF  JOINTS 


is  then  withdrawn,  and  the  femur  is  divided  by  very  gentle  sawing. 
The  limb  is  then  brought  into  a  position  of  abduction  and  nearly 
full  extension  (Figs.  500  and  501).  Tenotomy  of  the  adductors  may 
be  necessary  to  secure  abduction.  The  limb  is  then  fixed  in  this 
position  in  plaster  of  Paris,  and  is  treated  as  a  recent  fracture.  At 
the  knee,  formal  excision  (p.  469)  usually  will  secure  a  useful  and 
straight  limb,  though  still  ankylosed;  attempts  at  arthroplasty  in 
tuberculous  knees  are  to  be  condemned.  An  ankylosed  elbow  causes 
great  disability  even  "if  ankylosis  has  occurred  at  the  best  possible 
angle,  and  excision  may  properly  be  done  with  the  aim  of  restoring 
motion.    The  same  is  true  of  the  shoulder. 


Fig.  502.  —  SkiaRraph  of  tulx-rculosis  of  left  hii>joint.  Boy,  aged  five  years, 
duration  five  months.  Note  al)duction  and  flexion  of  thigh;  absorption  of  head  of  femur 
and  involvement  of  acetabulum.    Orthopiedic  Hospital. 


Tuberculosis  of  the  Hip. — Pathology  — The  primary  lesion  is  in 
the  neck  or  head  of  the  femur  in  most  cases,  but  occasionally  the 
acetabulum  or  synovia  is  first  involved.  Acetabular  and  synovial 
disease  are  intra-articular  from  the  beginning;  and  a  femoral  lesion 
very  soon  penetrates  the  joint,  the  epiphysis  of  the  head  being  intra- 
articular. Thus  in  all  cases  invasion  of  synovia  occurs  early,  and  in 
many  the  acetabulum  remains  healthy  for  only  a  short  period.  There 
is  marked  rarefaction  of  the  bone,  nearly  all  calcareous  matter  dis- 
appearing; the  skiagraphic  picture  (Fig.  502)  is  not  unlike  that  of 
round-celled  sarcoma  of  bone  in  the  total  obliteration  of  all  land- 


TUJJERCrLOSIS  OF   THE  HI!' 


489 


marks.  If  wci^flit-beariii^  is  contimicd,  the  acctiiimliiiii  may  he 
enlarged  iij)\v;ir(l  and  hackward  ("  waiidcriiij:;  acctahuliim"),  and 
patlioloj^ical  luxation  may  occur;  if  this  is  an  early  symptom  in  cases 
in  which  wci^dit-hcariuj;  lias  not  been  allowed,  it  generally  is  due  to 
rupture  of  the  cai)sule  from  intra-articular  effusion.  The  head  of  the 
femur  may  become  very  much  altered  in  shape,  or  entirely  absorbed; 
and  when  secondary  pyoj^enic  infection  is  present,  patholof^ical  fracture 
of  the  neck  is  not  very  rare  (Fig.  495).  The  best  result  in  such  cases 
is  firm  ankylosis  (Fig.  .'03). 


Fig.  503. — ."t-kiagraijli  of  ankylosis  of  right  hip  following  tuberculosis.  Girl,  aged 
thirteen  years;  coxalgia  at  nine  years:  no  symptoms  for  two  years;  healed  sinus  present 
in  groin.    Note  obliquely  contracted  pelvis.    Orthopaedic  Hospital. 

Symptoms  and  Clinical  Course. — When  early  symptoms  of  tuber- 
culous joint  disease  (p.  479)  point  to  the  hip,  the  patient  should  be 
attentively  examined  after  removal  of  all  clothing  from  the  waist 
down.  Nearly  90  per  cent,  of  cases  are  in  children  under  ten  years 
of  age.  First  the  gait  (bare-footed)  should  be  studied :  usually  a  slight 
limp  will  be  noted;  and  in  the  early  stages  the  thigh  is  held  in  slight 
flexion  and  abduction,  causing  flattening  of  the  buttock  and  obliteration 
of  the  gluteal  fold  on  the  affected  side  (Fig.  504).  The  patient  is  then 
laid  flat  on  his  back  on  a  firm  table:  measurements  from  the  navel  to 
the  malleoli  may  show  apparent  lengthening  of  the  affected  extremity; 
this  is  due  to  its  abduction,  but  if  the  healthy  limb  is  placed  in  a 


490 


DISEASES  OF  JOINTS 


similar  degree  of  abduction  the  discreijancy  will  disappear.     Unless 
there  is  marked  bone  deformation  or  dislocation  there  can  be  no  actual 


change  in  the  length  of  the 


Fig.  504. — Tuberculosis  of  the  left 
hip.  First  stage:  flexion  and  abduc- 
tion; flattening  of  buttock  and  oblit- 
eration of  the  gluteal  fold.  Age  five 
years;  duration  two  months.  Ortho- 
pcedic  Hospital. 


joint 


limbs.  Examination  usually  is  best 
begun  by  testing  the  motions  of  the 
normal  limb,  making  all  the  tests 
with  extreme  gentleness,  and  aiming 
to  gain  the  child's  confidence.  Usually 
the  affected  thigh  is  kept  slightly 
flexed  (Pig.  505),  and  when  an  at- 
tempt is  made  to  bring  it  out 
straight,  the  lumbar  spine  rises  from 
the  table  (Fig.  50())  because  the  hip 
is  held  rigidly  in  flexion,  and  motion 
is  transferred  to  the  spine.  First 
rotate  the  lower  extremity  gently  to 
and  fro  in  its  own  axis,  comparing 
the  motion  in  the  two  limbs;  there 
will  be  little  or  at  least  limited  rota- 
tion on  the  diseased  side,  and  it  will 
be  painful.  Then  try  abduction  of 
the  thigh,  still  keeping  the  limb  as 
fully  extended  as  possible;  on  the 
diseased  side  abduction  usually  is 
markedly  limited  by  the  muscular 
spasm.  The  range  of  flexion  is  next 
investigated,  first,  by  bringing  the 
sound  thigh  up  against  the  abdo- 
men, and  then  comparing  this  with 
this   usually    is    somewhat    limited. 


flexion    in    the   diseased 

but  not  so  markedly  as  rotation  and  abduction.     Next,  abduction 

with  the  thigh  flexed  to  a  right  ang'e  may  be  tested;  this  is  always 


Fig.  505. — Tuberculosis  of  right  hip  for  nine  months.  Age  three  years.  The  hip  is 
held  in  a  flexed  position  by  muscular  spasm,  and  the  lumbar  spine  lies  flat  on  the  table. 
(See  Fig.  506.)     OrthopEedic  Hospital. 


much  decreased  on  the  diseased  side.  Then  the  child  is  turned  over 
on  its  stomach,  and  the  range  of  hyperextension  is  tested  in  each 
hip  by  raising  the  knee  from  the  table;  this  movement  always  is 


TUBERCULOSIS  OF   Till':   H 1 1' 


491 


limited  Dii  the  diseased  side,  and  ulierc  marked  llexioii  det'ormity 
is  present,  it  is  manifestly  unnecessary  to  test  hyperextension.  11' 
any    of   tliese    motions   are   persistently,  even    if    only    very   slightly 


Fig.  o()(J. — 'rulicrciilosis  of  iiKht  \\\\^  (sec  Fig.  505),  showing  archiiii;  of  luniJjar  spine 
when  attoinpt  is  iiiadc  to  hriiifx  tlic  knee  down  on  the  tal)le.  Motion  occurs  in  the 
hnnl)ar  spine,  not  in  tlie  hip-joint.     Ortlioptedic  Hospital. 

limited,  and  if  there  is  a  history  typical  of  the  onset  of  tuberculous 
arthritis,  the  diagnosis  may  he  considered  established;  and  if  an  exami- 


FiG.  507. — Deformity,  following  tuber- 
culosis of  hip:  adduction  and  shortening 
(six  inches).  Age  sixteen  years;  onset 
of  disease  at  three  years;  healed  sinuses. 
No  symptoms  for  the  last  eight  years. 
Orthopaedic  Hospital. 


Fig.  508. — Extreme  exterior  rotation 
following  tuberculosis  of  hip.  Age  twelve 
years.  Duration  four  years;  sinuses  still 
open.  (Dr.  Alexander's  case.)  Episcopal 
Hospital. 


nation  such  as  above  indicated  were  systematically  made  by  the 
physician  first  called  to  attend  the  patient,  and  if  proper  treatment 
were  instituted,  valuable  time  would  be  saved.    Only  too  frequently 


492 


DISEASES  OF  JOINTS 


the  family  physician  makes  no  physical  examination  at  all,  or  only 
a  partial  one,  hampered  by  the  patient's  clothing;  and  treatment 

for  a  sprain  or  for  rheumatism  is  pre- 
scribed, when  a  very  little  more  trouble 
would  have  enabled  a  correct  diagnosis 
to  be  made.  In  the  rare  cases  where 
the  signs  are  so  slight  as  to  render 
a  positive  diagnosis  hazardous,  the 
surgeon  will  consult  his  own  and  the 
patient's  interests  much  better  by 
enjoining  recumbent  treatment  for  a 
week  or  two,  than  by  making  light 
of  the  malady. 

At  a  later  stage  of  the  disease,  the 
early  deformity  of  abduction  is  replaced 
l)y  adduction,  possibly  owing  to  atrophy 
of  the  iliopsoas  which  lies  closest  to 
the  joint,  and  the  unapposed  action 
of  the  adductors.  In  efforts  to  walk 
the  patient  has  to  bring  the  lower 
extremities  parallel,  and  as  the  dis- 
eased limb  is  fixed  in  adduction,  the 
healthy  limb  must  be  abducted  to 
correspond;  this  causes  a  descent  of 
the  pelvis  on  the  unaffected  side,  and 
apparent  shortening  of  the  diseased 
extremity.  But  if  the  healthy  limb 
is  placed  in  a  similar  attitude  of 
adduction,  the  measurements  will  be 
found  the  same,  unless  bone  destruction  or  dislocation  is  present. 
The  deformity  of  flexion  and  adduction,  in  this  which  is  called  the 
second  stage  of    "coxalgia,"   may  be  due  in  part  to  intra-articular 


Fig.  509. — Cold  abscess  of  left 
thigh,  from  tuberculosis  of  hip. 
Sequestrum  discharged  later.  Age 
four  years;  duration  three  years. 
Orthopaedic  Hospital 


Fig.  SlO.^GIuteal  abscess  in  coxalgia.     (Dr.  Hodge's  case.)     Children's  Hospital. 

changes,  but  most  of  it  is  due  to  muscular  contractures  which  may 
be  overcome  by  joint  fixation  and  traction. 


TUBERCULOSIS  OF   Till':   /III'  493 

At  a  still  later  stage  of  the  disease  the  patient  may  come  under 
observation  with  cold  abscess  or  simises,  and  with  ankylosis  in  almost 
any  jjosition  fFij^s.  '){)7  and  508),  or  with  patholoj^dcal  luxation.  Told 
abscesses  and  sinuses  usually  are  in  direct  comnuuiication  with  the 
joint  cavity,  but  occasionally  are  due  to  extra-articular  perforation 
of  the  l)one.     The  abscess  may  ])()int  at  any  part  of  the  thifi:h,  but 


Fig.  511. — Adductor  ahscess  in  coxalfria.     Ago  six  years.     C'oxalgia  for  one  j'ear. 
Abscess  for  four  weeks.     Orthopaedic  Hospital. 

the  most  frequent  site  is  on  the  outer  side  (Fig.  509);  or  a  gluteal 
abscess  (Fig.  510)  may  occur,  usually  from  perforation  of  the  poste- 
rior capsule.  x\bscesses  or  sinuses  in  the  adductor  region  (Fig.  511) 
usually  are  an  eA'idence  that  the  acetabulum  is  involved,  as,  accord- 
ing to  Vincent  (1895)  is  the  occurrence  of  adduction  as  the  primary 
deformitv. 


Fig.  512. — Bed  extension  for  coxalgia  with  flexion  deformity.     Note  the  high 
cradle  to  keep  the  bed-clothes  ofT  the  foot.     Episcopal  Hospital. 

Diagnosis. — Not  every  case  of  arthritis  of  the  hip  is  tuberculous, 
even  io  children,  and  where  doubt  exists  as  to  the  etiological  factor, 
other  aids  may  be  called  in  to  assist  the  clinical  diagnosis,  such  as  the 
tuberculin  tests,  estimation  of  the  leukocytes,  and  skiagraphy.    Nor 


494 


DISEASES  OF  JOINTS 


should  the  surgeon  forget  that  other  aflFections  besides  arthritis  may 
cause  rigidity,  flexion,  adduction,  etc.  Among  such  may  be  mentioned 
inguinal  or  femoral  adenitis,  psoas  abscess  (p.  607),  and  even  appendi- 
citis. Attention  to  the  clinical  history  and  physical  signs  will  exclude 
such  affections  as  fracture  of  the  cervix  femoris,  congenital  or  trau- 
matic dislocation  of  the  hip,  coxa  vara,  and  deformity  from  infantile 
arthritis. 

Treatment. — Recumbency  should  be  insisted  on  in  all  early  cases, 
with  weight  extension  of  two  or  three  pounds  applied  in  the  axis  of 
the  deformity  (Fig.  512).     Sufficient  fixation  usually  is  secured  by 


Fig.  513. — Thomas  hip  brace. 
Episcopal  Hospital. 


Fig.  514. — Thomas  hi])  brace; 
rear  view. 


strapping  the  body  to  a  Bradford  frame.  If  this  cannot  be  procured, 
a  binder's-board  splint  or  light  plaster  cast  may  be  applied  to  the 
hip  and  pelvis,  weight-extension  being  used  in  addition.  In  most 
cases,  after  a  week  or  two,  muscular  spasm  disappears  and  full  ex- 
tension may  be  secured.  The  temperature  should  be  recorded  twice 
daily,  in  this  as  in  all  acute  tuberculous  conditions;  it  forms  a  valu- 
able guide  as  to  the  progress  of  the  local  lesion.  After  one  or  two 
months  of  recumbency  examination  may  disclose  an  apparently  nor- 
mal joint,  and  the  temperature  curve  may  be  quite  satisfactory; 
but  this  merely  indicates  that  the  disease  is  latent,  not  that  it  is 
cured. 


TUBERCULOSIS  OF   THK  J/Il' 


49.5 


\\'lii'ii  s\  luptums  have  hocn  al)sent  for  a  luoiitli  or  more,  aiiil)ula- 
tory  treatment  may  be  cautiously  tried.  In  this,  joint  fixation  may- 
be jixadually  relaxed,  but  weight-bearing  should  be  prevented  for  a 
long  time  to  come.  \'arious  braces  are  in  use  for  this  stage  of  treat- 
ment: with  all,  a  high  shoe  is  worn  on  the  healthy  side,  and  crutches 
are  used,  allowing  the  diseased  limb  to  swing  free  of  the  ground.  The 
brace  of  II.  O.  Thomas  (1875)  (Figs.  513  and  514),  prox idea  fixation 
at  the  hi]),  and  traction  is  secured  by  the  weight  of  the  limb;  l)ut  it 
is  impossible  for  the  })atient  to  sit  down  with  the  brace  on,  and 
the   limb  may  rotate  within  the   brace,  giving  rise  to  unsuspected 


H^:i ' 

5 

^^^^H     ^    ^M^ 

I 

1 

^H/^K^^ft  ^     |k.'-< 

i 

1 

jJTjHM^^M^sli^l^HHKi^ 

m 

Fig.  .515.- 


-Taylor  hip  brace.     Episcopal 
Hospital. 


Fig.  516. — G.  G.  Davis's  brace  for 
coxalgia.    Orthopa?dic  Hospital. 


deformity.  About  1855  H.  G.  Davis  introduced  the  method  of  traction 
in  ambulatory  splints;  a  modification  of  this,  introduced  in  1873  by 
C.  F.  Taylor  (Fig.  515),  consists  of  a  pelvic  band,  passing  around  the 
pelvis  between  the  anterior  superior  iliac  spines  and  the  level  of  the 
great  trochanters,  to  which  is  attached  a  long  outside  iron  extending 
below  the  foot  beneath  which  it  forms  a  stirrup;  to  the  stirrup  traction 
straps  are  fastened  from  the  foot,  counter-extension  being  provided 
by  a  perineal  strap.  Movements  of  flexion  and  extension  are  per- 
mitted at  the  hip,  as  the  outside  iron  is  jointed  below  the  pelvic  band; 
this  allows  a  sitting  posture  to  be  assumed.     A  more  efficient  brace 


496  DISEASES  OF  JOINTS 

is  that  of  G.  G.  Davis  (Fig.  510),  in  which  besides  a  perineal  strap  for 
counter-extension,  as  in  the  Taylor  brace,  an  inside  iron  is  added 
which  supports  a  well-padded  bar  passing  from  one  side  iron  to  the 
other  beneath  the  tuber  ischii;  on  this  bar  the  patient  sits,  absolutely 
preventing  weight-bearing  on  the  diseased  joint,  while  the  foot  exten- 
sion keeps  the  lower  extremity  taut,  aiding  the  weight  of  the  limb 
in  securing  traction.  If  braces  cannot  be  secured,  a  spica  bandage 
of  plaster  of  Paris  may  be  applied  to  the  thigh  and  pelvis,  preferably 
fixing  the  knee  and  ankle  also;  and  with  a  high  shoe  on  the  sound  side, 
and  crutches,  the  patient  may  do  well,  though  a  well-fitting  brace  is 
much  more  cleanly  and  comfortable.  Usually  it  is  well  for  the  brace  to 
be  worn  night  and  day  at  first,  until  it  is  certain  that  no  recurrence  of 
symptoms  is  to  be  feared,  when  it  may  be  left  off  at  night.  While 
a  patient  is  wearing  a  brace,  he  should  be  seen  by  the  surgeon  every 
two  or  three  weeks;  and  the  surgeon  should  himself  see,  personally, 
that  the  brace  fits  comfortably  and  is  efficient.  If  he  is  unwilling 
or  unable  to  undertake  the  responsibilities  of  mechanical  treatment, 
he  should  retire  from  the  case. 

If  it  is  found  that  under  ambulatory  treatment  symptoms  of 
coxitis  return,  recumbent  treatment  should  be  resumed,  and  carried 
out  as  already  indicated.  When,  however,  ambulatory  treatment 
succeeds,  joint  fixation  may  be  gradually  dispensed  with.  If  eight 
months  or  a  year  are  passed  without  any  symptoms  whatever  of 
joint  trouble,  it  probably  will  be  safe  to  discard  the  brace,  but  a 
high  shoe  on  the  sound  side  and  the  use  of  crutches  should  be  insisted 
on  for  a  much  longer  period.  Then  the  high  shoe  may  be  abandoned, 
and  crutches  alone  used,  until  by  very  gradual  stages  weight-bearing 
is  proved  safe. 

I  am  well  aware  that  some  orthopedic  surgeons  at  present  are 
opposed  to  such  conservative  measures,  and  prefer  to  follow  the 
example  of  Lorenz  (1906),  in  treating  all  early  cases  of  coxalgia  by 
weight-bearing,  fixing  the  joint  in  the  attitude  of  deformity  by  a 
gypsum  splint,  and  abolishing  recumbency  and  traction  entirely 
from  their  plan  of  treatment.  But  the  plan  here  recommended  seems 
to  me  the  most  rational  when  the  pathology  of  the  lesions  is  con- 
sidered, and  is  still  employed  by  the  majority  of  judicious  surgeons 
in  this  country.  Great  Britain,  and  France;  and  I  am  convinced  that 
if  rigorously  employed  from  the  earliest  stage,  it  will  cure  a  much 
larger  proportion  of  patients  without  ankylosis  than  will  the  method 
of  Lorenz,  though  the  course  of  treatment  may  be  longer. 

The  treatment  of  cold  abscess  and  sinuses,  with  secondary  infection, 
has  been  so  fully  discussed  at  p.  4S4,  that  little  need  be  said  here.  In 
almost  all  cases  recumbent  treatment,  and  heliotherapy,  alone  or  with 
bismuth  or  iodin  injections,  will  cause  sinuses  to  close  eventually.  Very 
rarely  it  may  be  necessary  to  remove  a  sequestrum  or  some  carious 
bone  by  the  curette;  then  the  cavity  should  be  filled  with  iodoform 
bone-wax  (p.  435).  Almost  never  is  formal  excision  necessary  or 
desirable  in  children,  and  then  only  to  avert  death  from  sepsis,  and 


rVHERCrLOSIS   OF    THE   Ull' 


497 


as  a  less  severe  remedy  than  amputation,  I  liave  done  only  two 
excisions  of  the  hip,  employed  as  a  last  resort  in  cases  of  profuse 
suppuration  and  prolonged  liectic:  one  hoy  (Fig.  40"))  recovered  with 
the  usual  shortened  and  detormed,  tiiough  useful  limh  (Figs.  ")17and 
518);  the  other,  though  temporary  improvement  was  secured  (Fig.  '.V2), 
died  two  months  later  from  tuberculous  meningitis.  Excision  of  the 
hi})  for  tuberculosis  siiould  l)e  regarded  merely  as  a  method  of  joint 


Fig.  517. — Ridult  (jf  excision  of  hip  for 
tuberculosis,  in  a  boy  of  fourteen  years, 
one  year  after  operation.  (Dr.  H.  C. 
Deaver's  case.)  (See  Fig.  518.)  Epis- 
copal Hospital. 


Fig.  518. — Excision  of  left  hip  for 
coxalgia;  age  fourteen  jears.  Left  hij) 
in  slight  adduction;  apparent  shortening 
three  inches,  actual  shortening  one  and 
a  half  inches;  still  uses  crutches;  wound 
dry  but  scabby;  one  j^ear  after  operation. 
Episcopal  Hospital. 


disinfection  (Coudray,  1911),  and  should  be  as  conservative  in  extent 
as  is  possible  with  such  end  in  view.  An  anterior  incision  is  best, 
as  originally  advocated  by  Hueter  (1878),  and  later  adopted  by 
R.  W.  Parker;  this  incision  is  made  on  the  outer  side  of  the  sartorius, 
displacing  the  rectus  and  ilio-psoas  to  the  inner  side  (Barker,  1888) ; 
as  much  synovia  should  be  removed  as  possible.  In  very  septic  cases 
the  posterior  longitudinal  incision  is  preferable.  This  was  u.sed  by 
C.  White,  of  Manchester  (1769),  and  was  known  during  the  nineteenth 
32 


498 


DISEASES  OF  JOINTS 


century  by  Langenbeck's  name.  After  detaching  the  muscles  from 
the  great  trochanter  the  femur  is  divided  below  this  process,  the 
entire  upper  end  being  removed;  the  acetabulum  also  is  gouged  away 
if  necrotic.  Though  the  immediate  mortality  of  the  operation  is 
only  about  5  per  cent.,  yet  when  employed  for  the  cases  here  described 
as  suitable  for  such  treatment,  the  ultimate  death  rate  is  from  20 
to  25  per  cent.  If  employed  in  less  severe  cases  in  which  it  is  not 
necessary,  the  death  rate  will,  of  course,  be  less.  Amputation  occa- 
sionally may  save  a  life  after 
excision  and  re-excision  have 
failed.  After  the  operation 
recumbent  treatment  with 
fixation  and  traction  is  con- 
tinued until  latency  of  symp- 
toms indicates  the  propriety 
of  passing  to  ambulatory 
treatment.  Ankylosis  should 
be  encouraged.  '  Ely  (1911) 
thinks  the  benefit  of  excision 
in  hip  disease  is  due  to  the 
luxation  of  the  femur  which 
often  results,  thus  perma- 
nently abolishing  the  joint  as 
such,  as  effectually  as  would 
ankylosis  (p.  481). 

In  adults,  in  whom  tuber- 
culosis of  the  hip  is  rare,  ex- 
cision is  more  often  required, 
but,  fortunately,  the  resulting 
disability  is  less. 

Tuberculosis  of  the  Knee. 
— This  is  the  most  frequent 
form  of  tuberculous  joint  dis- 
ease in  adults,  in  whom  the 
primary  lesion  often  is  syno- 
vial; but  the  knee  is  often 
attacked  in  children  also, 
and  in  them  usually  the 
femur,  tibia,  or  patella  is 
first  involved.  In  the  knee, 
as  in  the  elbow,  local  signs  of  arthritis  are  much  more  marked 
than  in  the  hip,  consisting  in  heat,  dusky  redness,  typical  fusiform 
swelling,  and  occasionally  in  intra-articular  eft'usion.  Usually,  how- 
ever, enlargement  of  the  joint  is  due  to  fungus  granulation  tissue,  and 
though  it  may  seem  as  if  fluctuation  was  present,  aspiration  will  fail 
to  demonstrate  fluid.  The  patella  does  not  float,  but  early  becomes 
fixed  more  or  less  firmly  to  the  condyles  of  the  femur  (Fig.  519). 
The   knee   is   flexed,   and   contractures   of   the   hamstrings   develop. 


Fig.  519. — Skiagraph  of  tuberculous  arthritis 
of  knee;  age  thirty-seven  years;  duration  seven 
years.  Same  patient  as  in  Fig.  520.  Episcopal 
Hospital. 


TUBERCULOSIS  OF   THE   KNEE 


499 


In  iulvaiurd  cases  iiostcrior  sul)luxati()ii  of  tlio  tibia  (occurs,  usually 
accoinpaniod  also  hy  rotation  outward.  Starting  pains  are  very 
annoying,  and  the  patient  lies  curled  uj)  on  the  diseased  side,  his 
whole  attention  apparentl\-  concentrated  in  protecting  the  painful 
joint  from  injur>-  or  motion.  Cold  abscess  is  rarer  than  in  hip  disease, 
and  sinuses  more  freciuently  are  of  extra-articular  origin. 

Treatment.    -The  treatment  consists  in  local  rest,  secured  in  acute 
cases  by  recumbency  with  splinting  and  weight-extension.      In  less 
severe    cases   the    fixation 
by  plaster  of  Paris  without 
traction  may  suffice,    and 
if  the  gypsum  is  renewed 
every   four   or   five   weeks 
gradual  decrease  of  the  de- 
formity   may    be    secured. 
Weight  -  bearing       usually 
should    be   allowed    before 
motion  at    the    knee,    but 
for  some  months  after  am- 
bulatory treatment  is  com- 
menced it  is  safer  to  employ 
a  traction  brace,  much  the 
same    as    in    hip    disease, 
with  a  high    shoe  on  the 
healthy  foot,  and  crutches. 
If  conservative  treatment 
is  persisted  in  for  a  year, 
and  the  disease  fails  to  be- 
come latent,   the  question 

of  operative  treatment  may 

arise :  in  children  below  the 

age   of    puberty    all    that 

should    be     attempted     is 

erasion  of  the  joint  (arth- 

rectomy,     p.     486);     and 

though    by  resort    to    this 

operation  the  disease  may 

not  be  permanently  cured, 

and  though,  as  is  frequent, 

flexion  deformity  develops 

after  operation,  it  may  be 

possible  by  its  aid  to  tide 

the  patient  over  the  years 

of  childhood  until  formal  excision  can  be  safely  done.     In  adults  the 

results  of  conservative  treatment  are  very  disappointing  (Fig.  520) ; 

if,  after  judicious  trial  of   this  for  some  months,  no  improvement 

occurs,  or  if  the  disease  constantly  lights  up  afresh  when  ambulatory 

treatment  is  adopted,  excision  of  the  knee  should  be  done;  and  m 


Fig.  520. — Skiagraph  of  tuberculous  arthritis  of 
knee,  showing  destruction  of  external  condyle  of 
femur,  external  tuberosity  of  tibia  and  perforation 
of  cartilage  of  tibia.  Age  thirty-seven  years; 
duration  seven  j^ears.  Probably  synovial  in 
origin.     Treated  by  excision.    Episcopal  Hospital. 


500 


DISEASES  OF  JOINTS 


practically  all  cases  in  adults  with  sinuses  or  secondary  infection, 
early  excision  will  give  the  best  results  (Fig.  521).  The  ojjcration 
has  been  described  at  p.  469.  Ankylosis  should  be  firm  in  eight 
to  ten  weeks.  Even  if  excision  fails  to  cure  the  disease  at  once, 
which  rarely  is  the  case,  the  surgeon  must  not  conclude  that  immediate 
amputation  is  necessary;  by  persistence  in  conservative  measures,  firm 
ankylosis  and  healing  of  sinuses  may  yet  occur;  or  a  re-excision  may 
be  more  successful.  Amputation  should  be  regarded  as  the  last 
resort,  chiefly  adapted  to  the  very  old.  By  excision  the  limb  will  be 
shortened  from  one-half  to  two  inches.  During  convalescence  from 
operation  the  tendency  to  development  of  genu  \arum  must  be 
guarded  against,  as  well  as  the  tendency  of  the  femur  to  ride  for- 
ward on  the  tibia.  The  patient  should  wear  an  orthopedic  apparatus 
to  fix  the  knee  for  a  year.  The  immediate  mortality  of  the  operation 
is  about  5  to  10  per  cent. 


Fig.  521. — Specimen  from  excision  of  left 
knee  for  tuberculosis.  (See  Figs.  519  [and 
520.)   Episcopal  Hospital. 


Vic.  52l'. — Tul)t'rcul<)sis    of   left 
ankle-joint.     Episcopal  Hospital. 


Tuberculosis  of  the  Ankle  and  Tarsus. — The  diagnosis  sometimes 
is  difficult  in  children  or  adolescents,  in  whom  painful  flat-foot  (p.  547) 
may  be  the  primary  symptom.  The  astragalus  and  calcaneum  are 
the  bones  most  often  affected,  but  owing  to  the  proximity  of  so 
much  synovial  membrane  (Fig.  165),  early  joint  invasion  occurs  (Fig. 
522),  and  fistulization  with  secondary  infection  is  very  common. 

Treatment. — Treatment,  even  when  the  diagnosis  is  only  tentative, 
should  be  by  rest  and  cessation  of  weight-bearing,  secured  by  a  gypsum 
case  and  use  of  crutches.  This  usually  is  sufficient  in  children,  in 
whom  sinuses  soon  close,  and  erasion  rarely  is  required.  If  motion 
is  prevented  by  a  suitable  brace,  weight-bearing  may  be  resumed  a 
few  months  after  cessation  of  active  symptoms.  In  adults,  on  the 
other  hand,  time  should  not  be  lost  in  conservative  treatment  unless 
improvement  is  progressive;  if  the  disease  seems  stationary,  and 
especially  if  the  foot  grows  worse,  erasion  or  excision  should  be  resorted 


TUBERCULOSIS   OF    THE-   F.LIiOW 


501 


to   without  (Ichiy.     The  entire  astragalus  should  he  renioNi-d,  and  as 
much  of  the  t ulxrculous  soft  parts  as  p()ssil)le.     Usually  the  sur},'eon 


Fig.  o2'.i. — Tiil^erculosis  of  elbow  in  a 
child  of  four  years,  showing  typical 
fusiform  .swellinji;  also  tuberculous  spon- 
dylitis, and  tuberculous  osteomyelitis 
of  left  forearm  and  hand  with  sinuses. 
This  condition  iseuphonioiisly  descrilied 
as  the  "moist rot."  Children's  Hospital. 


Fig.  524. — Tuberculosis  of  elbow. 
Age  seven  years;  duration  four  years; 
sinuses  for  four  months.  Also  tuber- 
culous cervical  adenitis.  (See  Fig.  525.) 
Orthopedic  Hospital. 


finds  that  he  has  delayed  too  long,  and  that  while  this  con- 
servative operation  may  improve  matters  for  a  while,  amputation 
eventually  will  be  necessary. 
Tuberculosis  of  the  Elbow 
is  much  more  frequent  in 
children  than  in  adults.  The 
primary  lesion  is  more  often 
in  the  ulna  or  humerus  than 
in  the  radius.  Joint  invasion 
is  rapid,  and  typical  fusi- 
form enlargement  results 
(Fig.  523).  Fistulization  is 
difficult  to  prevent  (Fig. 
524),  and  cure  seldom  oc- 
curs except  by  ankylosis, 
and  it  is  better,  especially 
in  children,  to  encourage 
ankylosis  and  closure  of 
sinuses  than  to  resort  to 
precocious  excision  (Fig. 
525).    No  effort   should  be 

made  to  restore  motion  until   all   symptoms  have  been  absent  for 
many  months.     Then  an  excision  or  arthroplasty  may  be  done. 


Fig.  525. — Tuberculous  ell)ow,  fibrous  anky- 
losis, sinuses  healed.  Age  ten  years.  Three  and 
a  half  years  after  Fig.  524. 


502 


DISEASES  OF  JOINTS 


Tuberculosis  of  the  Wrist. — This  is  rare  in  children;  immobilization 
promptly  employed  and  long  continned  usnally  prodnces  a  cure  with 
only  moderate  limitation  of  mot  on.  In  adults  sinuses  are  prone 
to  form,  and  amputation  is  the  usual  termination,  though  erasion 
should  be  tried  first.  Formal  excision  of  the  wrist  is  very  rarely 
advisable  (p.  470);  firm  fibrous  ankylosis  is  songht,  and  the  hand 
seldom  is  verv  useful. 


Fig.  526. — Syphilitic  arthritis  of  left  elbow. 
Ago  fourteen  years:  duration  two  years.  Also 
interstitial  keratitis  and  slight  sabre-blade 
tibia.    Orthopsedic  Hospital. 


Fii,.  .j_'7.  —  S\  jiliilitir  arthritic  of 
both  knees.  Age  thirteen  year.s;  dura- 
tion five  months.  Orthopsedic  Hos- 
pital. 


Tuberculosis  of  the  Sacro-iUac  Joint  is  very  rare,  especially  in 
children.  The  symptoms  are  pain,  sometimes  radiating  down  the 
sciatic  nerve,  localized  tenderness  over  the  affected  joint,  and  a 
peculiar  feeling  of  insecurity  in  the  pelvis  on  attempts  to  walk.  When 
standing,  the  body  is  inclined  away  from  the  diseased  side,  as  in 
"  sciatica. "  Examination  shows  no  involvement  of  the  hip  or  vertebrae ; 
hyper-flexion  of  the  hip  on  the  diseased  side  occurs  to  the  normal 
extent  unless  the  knee  is  kept  extended,  when  it  will  be  impossible 
to  flex  the  hip  as  far  on  the  diseased  as  on  the  healthy  side,  since 
muscular  spasm  will  be  roused  by  traction  on  the  ischium  through 
the  tense  hamstrings.  Pressing  the  iliac  crests  together,  and  attempts 
at  antero-posterior  motion  in  the  pelvic  joints  cause  pain.  In  advanced 
cases  swelling  over  the  dorsal  or  pelvic  surface  of  the  joint  occurs, 
and  suppuration  may  develop,  with  sinuses  posteriorly  or  in  the 
inguinal  or  adductor  regions. 

Treatment. — Recumbency,  with  weight-extension  for  many  months, 
is  required.  No  form  of  apparatus  is  satisfactory  in  preventing 
weight-bearing  at  the  sacro-iliac  joint,  and  recurrence  of  symptoms 


TUMORS  OF  JOINTS  503 

is  not  iimisual  wlieii  ambulaton'  treatment  is  att('nij)t('(l.  A  few 
recoveries  have  i)een  reported  after  resection  of  tiie  joint,  but  even 
in  adults  tiiis  should  be  reserved  until  conservative  measures  have 
proved  inelfectual.  l^i((pie  (1910)  reports  seven  resections  of  the 
sacro-iliac  joint  for  tuberculosis:  two  patients  were  cured,  three  were 
recovering-  ("nearly  cured"),  one  died  of  cachexia,  and  the  last  had 
amyloid  dcireneration  of  the  viscera  and  death  was  anticipated. 

Syphilis  of  the  Joints. — Syphilitic  arthritis  is  not  very  rare  in  cases 
of  hereditary  lues,  but  often,  especially  in  the  acquired  form  of  the 
disease,  is  not  reco^ijnized.  In  its  clinical  aspects  the  disease  nuich 
reseml)les  tuberculous  arthritis,  especially  of  the  primary  synovial 
type,  but  pain  is  less  severe.  The  diagnosis  usually  is  made  from 
concomitant  evidences  of  syphilis  (Figs.  o2()  and  527),  and  is  confirmed 
by  the  AVassermann  reaction  and  results  of  antisy})hilitic  treatment. 
If  the  joint  is  painful,  suitable  apparatus  should  be  i)roNided. 

TUMORS  OF  JOINTS. 

Tumors  of  the  joints,  except  those  developed  from  the  neighboring 
bones,  are  quite  rare. 

Lipoma  Arborescens  is  the  name  given  by  Volkmann  (1882)  to 
a  synovial  or  subsyno\ial  growth  in  which  fatty  deposits  occur.  It 
is  observed  oftenest  in  the  knee,  along  one  side  of  the  tendo  patelhe, 
but  also  occurs  in  the  shoulder.  It  is  regarded  by  Poncet,  Marsh, 
Ely,  and  Whitman  as  tuberculous  in  nature,  and  there  is  no  doubt 
that  sometimes  it  is;  but  it  is  better  to  consider  it,  with  Nichols 
(1907),  a  hypertrophic  synovial  change  which  may  occur  in  various 
joint  afl'ections.  The  fatty  out-growth  is  more  or  less  pedunculated, 
is  palpable  through  the  skin  as  an  ill-defined  mass,  and  interferes 
with  the  functions  of  the  joint  without  producing  very  acute  symptoms. 
The  best  treatment  is  excision  of  the  growth. 

Sarcoma. — Primary  sarcoma  (endothelioma)  of  joints  is  rare.  It 
begins  in  the  synovia  or  subsynovial  connecti^'e  tissue.  Lejars  and 
Rubens-Duval  (1910)  have  collected  16  cases,  13  of  which  occurred 
in  the  knee.  This  is  one  of  those  neoplasms  where  transition  from 
epithelioid  to  sarcomatoid  tissue  is  best  observed.  The  clinical 
symptoms  somewhat  resemble  a  subacute  infectious  arthritis,  and  the 
diagnosis  usually  depends  on  microscopical  examination  of  an  excised 
specimen.  If  the  tumor  recurs  after  local  extirpation,  amputation 
should  be  done. 


CHAPTER   X\\  . 

ORTHOPEDIC  SURGERY. 

Orthopedics,  from  the  Greek  words  oaf^o;  and  ~«^c,  meaning  lit- 
erally a  straight  child,  is  that  part  of  surgery  which  deals  with  the 
correction  of  deformities,  either  congenital  or  acquired.  So  many 
surgeons,  during  the  last  fifty  years  or  more,  have  devoted  their  exclu- 
sive attention  to  this  subject,  that  the  practice  of  orthopedic  surgery 
is  now  recognized  as  a  specialty  of  equal  rank  with  gynecology  or 
genito-urinary  surgery.  In  the  limits  of  a  text-book  on  general  sur- 
gery, therefore,  it  is  manifestly  impossible  to  do  more  than  provide 
an  outline  of  the  subject,  and  inculcate  the  general  principles  which 
underlie  its  practice. 

CONGENITAL  DEFORMITIES. 

Congenital  Absence  of  Bones  is  not  very  rare.  Those  most  often 
deficient  are  the  radius,  and  the  tibia  or  fibula.  Sometimes  the  outer 
portion  of  the  foot  is  absent  along  with  the  fibula,  or  a  portion  of  the 
hand  absent  with  the  radius.  The  exact  diagnosis  often  depends  on 
skiagraphy.  The  hand  or  foot  deviates  toward  the  side  where  its 
support  is  lacking.  In  infancy  malposition  may  be  prevented  or 
corrected  by  splints,  or  other  apparatus.  Often  during  childhood 
or  adolescence  it  becomes  necessary  to  operate  for  the  correction  of 
deformity,  or  to  improve  function.  In  the  foot,  some  form  of  arthro- 
desis (p.  528)  usually  will  be  required  to  give  stability  in  walking,' 
while  in  the  upper  extremity  it  may  seem  desirable  to  lengthen  con- 
tracted muscles  and  tendons,  and  do  osteotomy  or  resection  of  the 
existing  bone  for  cosmetic  effect,  though  function  can  seldom  be 
improved. 

Osteoplastic  Operations. — After  resection  of  a  large  part  of  the 
diaphysis  of  a  bone,  for  osteomyelitis  or  tumor,  the  limb  often  is  left 
in  a  helpless  condition,  much  as  in  the  cases  of  congenital  deformity 
noted  above.  When  the  shaft  of  the  tibia  has  been  excised,  and  fails 
to  regenerate,  the  upper  end  of  the  fibula  may  be  moved  over  later 
to  a  socket  cut  in  the  upper  epiphysis  of  the  tibia  (Hahn,  1S84); 
in  cases  reported  by  Nichols  (1904),  Huntington  (1905),  and  others, 
the  fibula  underwent  hypertrophy  and  supported  the  weight  of  the 
body  very  well.    In  other  cases  a  portion  of  the  diaphysis  of  the  femur, 

^  Wille  (1909)  in  a  case  of  congenital  absence  of  the  fibula  did  arthrodesis  by 
driving  a  fibula  (obtained  from  an  amputated  leg)  up  from  the  sole,  through  the 
calcis,  astragalus,  and  tibia,  and  obtained  a  fair  result. 


CONGENITAL  DEFORMITIES 


505 


IniuuTiis,  or  otluT  long  bone,  lias  hocn  replaced  immediately  by 
traiisi)laiitiiig  a  jxtrtioii  of  tlu>  patient's  tibia,  ent  long  enongli  to 
fill  the  defect,  and  about  half  an  inch  in  diameter.  This  "trans- 
plant" must  be  brought  into  contact, 
at  least  at  one  end,  with  healthy  bone, 
containing  Ibnersiaii  systeins,  so  that 
the  osteoblasts  lining  these  may  grow 
along  the  channels  in  the  transplant, 
and  thus  lay  down  new  bone  in  place 
of  that  contained  in  the  transj)lant, 
which  is  slowl\' absorbed  by  the  osteo- 
clasts. If  the  transplant  is  not  brought 
into  contact  with  a  healthy  Haversian 
system,  it  will  not  l)e  j)ermeated  by 
osteoblasts,  but  will  be  gradually  ab- 
sorbed and  the  operation  will  be  a 
failure  (Murphy,  1912).  Many  sur- 
geons prefer  to  preserve  the  perios- 
teum of  the  transplant,  thinking  it 
favors  bone  growth.  I  have  always 
removed  the  periosteum  before  cut- 
ting the  transplant. 

Congenital    Absence    of    Muscles 
(Fig.  o2<S),  which  is  quite  rare,  seldom 
entails  much  disability;  when  it  does, 
it  usually  is  possible  to  improve  function  by  tendon  transplantation 
(p.  525),  or  insertion  of  artificial  ligaments  (p.  529). 


Fig.  528. — Congcnittil  abscrife  of 
costal  portion  of  right  pcctoralis 
major,  in  a  girl  of  six  years.  No 
disability.  Slight  scoliosis.  Ortho- 
paedic Hospital. 


Fig.  529. — Supernumerary  digits,  sLx  toes  on  each  foot.  Age  seven  months.  Also 
had  six  fingers  on  each  hand,  but  the  extra  fingers  were  amputated  at  birth.  Episcopal 
Hospital. 

Supernumerary  Fingers  or  Toes  (Polydactylism)  (Fig.  529)  usually 
require  amputation;  special  care  should  be  paid  to  hemostasis,  as 
deaths  in  infants  from  secondary  hemorrhage  have  been  reported. 


506 


ORTHOPEDIC  SURGERY 


Malformations  involving  the  metacarpal  or  metatarsal  bones  seldom 
can  be  appreciated  without  a  skiagraph  (Fig.  530),  and  require  special 
types  of  operation. 


Fig-  530. — Skiagraph  of  the  left  hand  o:  ^  piuen:,iig£d  nineteer.  years,  showing poly- 
dactylism  and  syndactylism.    The  right  hand  was  similarly  affected.    Episcopal  Hospital. 

Webbed  Fingers  Syndactylism)  (Fig.  531)  may  be  treated  by  several 
forms  of  plastic  operation.  Didot's  method  (1S5C)  is  sufficiently  indi- 
cated by  the  accompanying  figure  (Figs.  532).  There  is  great  ten- 
dency for  the  web  to  re-form,  and  it  always  is  well  to  carry  the  inci- 
sions far  down  between  the  heads  of  the  metacarpal  bones.  For  this 
reason  Agnew's  operation  ''Fig.  5.33)  is  preferable,  as  it  provides  a  flap 
of  healthy  skin  over  the  v,-eb. 

Congenital  Contraction  of  a  Finger  may  require  some  form  of  plastic 
operation,  after  excision  of  dense  bands  of  connective  tissue.  In  the 
case  represented  in  Fig.  534.  full  extension  became  possible  only  when 
the  anterior  ligament  of  the  interphalangeal  joint  was  divided. 


CONGENITA L  DISLOCA TIONS 


507 


Congenital    Dislocations.     Congenital    Dislocation    of    the    Hip    is 

(lif  most   t'r('(niciil  of  these  congenital  luxations.     Some  authorities 
believe  that  the  displacement  of  the  hones  may  not  always  date 


Fig.  .531.^ — Webbed  fingers;  age  fourteen         Fig.  532. — Didot's  operation  for  webbed 
years.    Orthopsedio  Hospital.  fingers. 

from  fetal  existence,  but  may  be  produced  by  uterine  contractions 
during  l)irth  (Allis,  1907),  or  after  birth  by  injudicious  attempts 
to  extend  the  baby's  thighs;  however,  it  is  very  generally  agreed 


Fig.  .533.  —  Agnew's  operation 
for  webbed  fingers. 


Fig.  534. — Congenital  contracture  of  fifth  finger; 
age  sixteen  years.     Episcopal  Hospital. 


that  there  is  a  congenital  malformation  of  the  acetabulum  and  of  the 
head  of  the  femur  or  both,  possibly  due  to  malposition  within  the 
uterus.  The  deformity  is  more  common  in  female  (85  per  cent.)  than 
in  male  (15  per  cent.)  children,  and  more  often  unilateral  (63  per 


508 


ORTHOPEDIC  SURGERY 


cent.)  than  bilateral  (30  per  cent.).  The  dislocation  is  posterior  in 
the  overwhelming  majority  of  cases.  The  longer  the  dislocation 
stays  unreduced  the  more  does  the  capsule  contract  around  the  acetab- 
ulum, forming  an  hour-glass-shaped  channel  through  which  it  may 
become  impossible  to  replace  the  head.  The  acetabulum,  which  is 
shallower  than  normal,  becomes  more  so  as  life  advances  unless  the 
femoral  head  is  replaced  in  it  and  normal  weight-bearing  is  restored. 

Symptoms. — Frequently  nothing  abnormal  a})out  the  child  is  noted 
until  walking  is  attempted,  when  a  limp  is  visible  in  the  unilateral 
cases  (Fig.  535),  and  a  characteristic  waddle  in  the  double  dislocations. 


Fig.  535. — Congenital  dislocation  of  left  hip,  in  a  boy  of  two  years.     Limp  first  noted 
on  attempts  to  walk  at  the  age  of  fifteen  months.     Episcopal  Hospital. 


Tn  the  latter  there  also  develops  marked  lordosis  (Fig.  536),  because 
the  centre  of  support  is  displaced  posterior  to  the  centre  of  gravity.  If 
the  dislocation  is  not  reduced,  deformity  and  disability  usually  increase 
with  age;  and  in  most  cases  adolescents  and  adults  must  lead  a  semi- 
invalid  existence.  The  diagnosis  is  made  from  the  history,  from  the 
symptoms  noted  above,  and  from  the  physical  examination.  This 
shows  moderate  shortening  of  the  extremity  affected  (Fig.  537) ,  eleva- 
tion of  the  trochanter  above  Xelaton's  line,  and  absence  of  the  femoral 
head  from  its  socket.  By  alternately  pulling  and  pushing  on  the  fully 
extended  lower  extremity,  while  the  pelvis  is  fixed,  the  great  trochan- 


CONGENITAL  DISLOCA  TIONS 


509 


ter  will  1)0  foiiiui  to  slide  up  iuid  down.  When  the  two  tliif^hs  are 
flexed  to  a  rifi;ht  an^lc,  with  the  knees  bent,  and  the  child  on  its  l)aek, 
the  thi<;h  on  the  afl'ected  side  is  found  shorter.  'Jliere  is  diminished 
abduction,  especially  when  the  thi^di  is  Hexed  to  a  ri^dit  angle.  Flexion 
and  (extension  are  free  and  painless,  facts  which  together  with  the 
history  readily  serve  to  distinguish  this  aflection  from  traumatic  dis- 
location. In  coxa  vara  the  head  of  the  hone  is  in  the  acetabulum;  and 
in  coxalgia  there  is  an  acute  arthritis, 
or  its  resultant  deformity.  Confirma- 
tion of  the  diagnosis  of  dislocation  is  ob- 
tained by  skiagraphy,  w'hich  usually 
shows  more  or  less  anicvcrsion  of  the 
head  of  the  femur:  that  is,  instead  of 
pointing  inward  toward  the  pelvis,  the 
neck  of  the  fenuir  lies  more  nearly  in  the 
sagittal  plane,  the  head  pointing  forward 
even  when  the  lower  limb  is  not  rotated 
outward. 

Treatment. — Reduction  should  be  ac- 
complished as  soon  as  the  diagnosis  is 
made.  In  very  young  children,  reduc- 
tion is  not  difficult  to  secure  by  the 
usual  methods  for  dislocation  of  the  hip 
(p.  408);  but  in  all  cases  reduction  is 
very  difficult  to  maintain  owing  to  the 
shallowness  of  the  acetabulum,  the  de- 
formation and  anteversion  of  the  head, 
and  the  resiliency  of  the  soft  parts. 
After  the  age  of  eight  or  nine  years  it 
is  ^'e^y  difficult  and  sometimes  impos- 
sible to  obtain  reduction  without  open 
operation,  wdiich  is  called  by  the  Ger- 
mans the  "bloody"  as  distinguished  from 
the  "bloodless"  method  of   reposition. 

Paci,  of  Pisa  (1888,  1894),  was  an  early  exponent  of  the  bloodless 
method,  which  he  systematized,  and  Lorenz  (1895)  abandoned 
his  bloody  method  to  take  up  a  modification  of  Paci's  operation, 
which  he  has  popularized  all  over  the  world.  The  child  being 
etherized  and  the  pelvis  fixed,  the  surgeon  flexes  and  then 
abducts  the  thigh  until  the  adductor  tendons  become  tense;  these 
are  then  ruptured  subcutaneously  by  blows  from  the  ulnar  side  of  the 
hand,  or  ])y  violent  massage.  The  limb  is  then  forcibly  hyperflexed, 
with  the  knee  extended,  until  it  lies  alongside  the  body,  with  the  foot 
beside  the  patient's  head.  When  all  resisting  soft  structures  on  the 
anterior  portion  of  the  joint  have  been  ruptured,  reduction  is 
attempted:  the  trochanter  is  placed  over  a  wedge-shaped  block,  and 
by  hyperabduction  of  the  flexed  thigh  the  surgeon  pries  the  head  of 
the  femur  into  its  socket.  The  clenched  fist  may  be  \ised  as  a  fulcrum 
instead  of  Lorenz's  wedge;  but  either  method  is  liable  to  fracture  the 


Fig.  536. — Lordosis  from  double 
congenital  dislocation  of  hips,  in  a 
girl  of  seven  years.  Orthopaedic 
Hospital. 


510 


ORTHOPEDIC  SURGERY 


cervix  femoris  (Tig.  o39).  According  to  Bade  0909),  nerve  injury, 
resulting  in  paralysis,  has  occurred  in  07  out  of  2204  cases  of  blood- 
less reposition;  and  many  surgeons  have  produced  one  or  more  frac- 
tures of  the  femur,  myself  included  (in  a  patient  over  eight  years  of 
age).  A  much  safer  and  equally  efficient  method  is  that  of  G.  G. 
Davis  (1907),  in  which  the  patient  is  placed  prone  on  the  table,  and 
the  thigh  is  flexed  until  it  lies  alongside  the  chest,  with  the  knee  in  the 
axilla;  this  brings  the  head  of  the  femur  below  but  still  posterior  to  the 
acetabulum;  then  the  adductors  are  gradually  stretched  by  manual 
pressure  downward  on  the  great  trochanter  (^Fig.  540) ;  when  these 


Fig.  537. — Congenital  di.slocation 
of  right  hip.  in  a  girl  eight  and 
a  half  years  old.  (See  Fia.  53S.) 
Orthopaedic  Hospital. 


Flo.  -JSS. — (.'o:. genital  di>l'jeation 
of  right  hip.  Three  and  a  half  years 
after  reduction.  Same  patient  as 
Fig.  537.    Orthopsedic  Hospital. 


structures  have  been  stretched  enough  to  allow  the  groin  to  come 
in  contact  with  the  table,  the  head  of  the  femur  ma>'  jump  from  the 
posterior  to  the  anterior  plane  of  the  pelvis  with  an  audible  and 
palpable  click.  If  not,  the  flexion  of  the  thigh  is  slightly  diminished 
{i.  e.,  it  is  drawn  a  little  away  from  the  chest)  and  its  abduction  is 
slightly  increased,  by  raising  the  knee  a  short  distance  from  the  table. 
Pressure  downward  on  the  trochanter  is  continued  until  the  head  of 
the  femur  can  be  felt  by  the  finger  in  the  groin.  If  reduction  cannot 
be  secured  at  the  first  attempt  without  the  use  of  unjustifiable  force, 
it  is  better  to  dress  the  limb  in  the  fullest  abduction  possible  and 


CONGEMTA  L    DISIJH  A  TIOXS 


511 


make  another  attcnij)!   sc\cral   weeks  later  il'  iieeessary,  after  sub- 
cutaneous  tlivision    of    tlie   adductor   muscles,  close  to  the   pubis. 
When  reduction  has  been  secured,  tiiis  fact  may  be  determined 

(1)  l)y  hearinj^  or  fecHng  the  femoral  head  junij)  into  tlie  acetabulum; 

(2)  by  observinjf  that  the  knee  can  no  lonj^er  be  fully  extended,  since 
the  ascent  of  the  femur  from  the  posterior  plane  of  the  innominate 


Fig.  539. — Fracture  of  neck  of  femur  when  hyper-abduction  is  attempted 
according  to  Lorenz's  method. 

bone  to  the  acetabulum  has  caused  a  relative  shortening  of  the  ham- 
strings; (3)  by  palpating  the  head  of  the  femur  in  its  socket  below 
Poupart's  ligament;  (4)  b}'  reproducing  the  luxation  and  again  redu- 
cing it;  and  (5)  by  skiagraphy.  Sometimes  an  "anterior  transposition" 
only  is  secured :  in  this  the  head,  instead  of  jumping  into  the  acetabu- 
lum, passes  above  it  to  a  position  just  below  the  anterior  superior  spine 


Fig.  540. — G.  G.  Davis's  method  of  reducing  congenital  dislocation  of  hijj. 
Orthopaedic  Hospital. 

of  the  ilium;  of  course  this  is  not  so  favorable  a  result  as  an  "anatomical 
reposition,"  but  it  is  better  than  a  persistence  of  the  dislocation,  since 
it  transfers  the  weight-bearing  point  to  the  centre  of  gravity. 

After  reduction  the  head  of  the  femur  is  not  at  all  stable  in  its  ill- 
formed  socket,  and  the  chief  difficulty  and  tedium  in  the  care  of  these 
cases  arises  in  the  after-treatment,  in  efforts  to  prevent  relapse.  The 
limb  should  be  dressed  in  plaster  of  Paris  in  the  most  stable  'position; 


512  ORTHOPEDIC  SURGERY 

usually  this  is  with  the  thigh  flexed  to  a  right  angle  and  abducted 
beyond  the  coronal  plane;  that  is,  so  that  the  knee  is  in  a  plane  2^05- 
terior  to  the  symphysis  pubis  (Fig.  541).    This,  the  "primary  position," 


Fig.  541. — Congenital  dislocation  of  right  hip;  primary  dressing.  Photographed 
two  weeks  after  operation.  Same  patient  as  Pigs.  537,  538,  and  543.  Orthopaedics 
Hospital. 


Fig.  542. — Frog  position  after  reduction  of  congenital  dislocation  of  both  hips. 
Orthopaedic  Hospital. 


CONGENITAL   DISLOCATIONS 


513 


called  also  the  "tVo^^  position"  wlicn  hotli  liij)s  arc  coiKHTiicd  (Fig. 
542),  must  l)c  iiiaintaiiicd  tor  from  four  to  six  months.  During  this 
time  the  child  nuist  be  encouraged  to  walk  about,  with  sup])ort,  as 
weijiht-bearing  favors  the  deepening  of  the  acetabulum.  At  the  end 
of  this  time,  unless  rcluxation  has  occurred  or  is  inuuincnt,  the  abduc- 
tion and  ilexion  may  be  diminished  gradually,  and  the  thigh  dressed 
in  a  less  awkward  position  (Fig.  543),  in  which  locomotion  is  easier. 
Sometimes  greater  stability  is  secured  by  dressing  the  limb  with  the 
patella  looking  directly  forward,  without  any  external  rotation  of  the 
thigh.  Innnobilization  of  the  hij)  nuist  be  coutiinied,  except  in  very 
young  children,  for  from  nine  to  eighteen  months  after  the  primary 
reposition,  and  for  a  similar  or  longer  period  after  any  recurrence  of 
dislocation  and  secondary  reposition. 
After  this  time  external  su])i)ort  may 
be  discontinued,  and  gentle  passive 
motion  and  massage  may  be  prescribed. 
The  younger  the  child,  the  sooner,  as 
a  rule,  can  external  support  be  dis- 
pensed with,  and  the  sooner  will  func- 
tion return. 

If  reluxation  recurs  persistently,  and 
in  cases  where  bloodless  reposition  is 
impossible,  a  resort  to  open  operation 
usually  is  proper.  The  best  approach 
is  by  an  anterior  incision,  along  the 
inner  border  of  the  sartorius.  HoflFa 
(ISOO)  used  a  posterior  incision  with 
temporary  resection  of  the  great  tro- 
chanter, but  later  abandoned  this 
method.  Lorenz  (1892)  used  an  in- 
cision from  the  anterior  superior  iliac 
spine  to  the  great  trochanter,  passing 
between  the  tensor  vaginae  femoris 
and  gluteus  medius;  I  have  used  this 
method  with  satisfaction.  Ludloflf 
(190(S)  uses  an  internal  incision,  pass- 
ing between  the  adductors  and  pecti- 

neus.  In  all  cases  the  capsule  is  widely  opened,  preserving  the 
Y-ligament;  and  the  acetabulum  is  cleared  out  sufficiently  to  hold 
the  head  of  the  femur.  Structures  preventing  reduction  should  be 
divided;  but  in  adults,  where  utmost  efforts  sometimes  fail  to  secure 
reduction,  it  may  be  sufficient  to  form  a  new^  socket  above  the 
acetabulum  (G.  G.  Davis,  1908).  A  certain  measure  of  relief  will  be 
secured  if  the  head  of  the  femur  becomes  more  firmly  fixed,  in  any 
position,  than  it  was  l)efore  operation. 

Congenital  Dislocation  of  the  Shoulder. — In  many  cases  it  is  prob- 
able that  the  displacement  occurs  during  obstetrical  delivery.     The 
dislocation   nearly   always  is  subspinous   (Fig.  544);  the  attitude  is 
characteristic;  and  the  diagnosis  easy.    Reduction  rarely  is  possible 
33 


Fig.  543. — Congonital  dislocation 
of  right  hip  in  walkiup;  cast.  Same 
patient  as  Figs.  537,  538,  and  541. 
Orthopsedic  Hospital. 


514 


ORTHOPEDIC  SURGERY 


Fig.  544. — Congenital  dislocation  of 
the  left  shoulder.  Age  seven  years. 
Orthopcedic  Hospital. 


without  open  operation.  This  dis- 
location not  infrequently  accom- 
panies the  condition  designated 
"brachial  birth  palsy,"  and  accord- 
ing to  T.  T.  Thomas,  the  dislocation 
is  the  essential  lesion  (p.  2S3). 

Congenital  Elevation  of  the  Scapula, 
Sprengel's  Deformity  (1891).— The 
upper  extremity  develops  as  an 
appendage  of  the  cervical  spine, 
and  if  normal  descent  of  the  scap- 
ula fails  to  occur,  it  remains  in  the 
cervico-dorsal  region,  more  or  less 
deformed,  often  being  fixed  to  the 
\'ertebral  spines  by  a  process  of 
bone  or  cartilage.  The  subject  has 
been  studied  recently  by  A.  E. 
Horwitz  (1908),  who  analyzed  136 
cases.  In  the  patient  under  my  own 
care  (Fig.  545),  who  also  presented 


Fig.  .545. — ( 'ongcnital  elevation  of  left 
scapula  in  a  boy  of  three  years;  before 
operation.     Orthopaedic  Hospital. 


Fig.  54(i. — ('ongcnital  elevation  of 
left  scapula,  three  months  after  opera- 
tion.    Orthopaedic  Hospital. 


CONGENITAL   T  A  LIVES 


515 


con^M'iiital  scoliosis  and  al)S('nce  of  several  rihs,  marked  iiiij)rovenient 
resulted  t'roin  open  section  of  the  muscles  attached  to  the  xertehrai 
border  of  the  scapula,  depression  of  the  scapula,  and  re-attachment 
of  the  rhomboids  to  the  upper  anjjle  of  the  bone  (Fig.  54()), 

Congenital  Dislocation  of  the  Knee  is  quite  rare,  and  usually  is 
anterior  in  direction,  the  leg  being  hyperextended  on  the  thigh.  The 
patella  may  be  absent.  The  use  of  splints  or  orthopedic  api)aratus 
usually  secures  a  return  to  the  normal  position,  with  moderate  range 
of  fl(>xion,  before  the  age  for  AA'alking  arrives. 

Congenital  Talipes. — The  cause  of  congenital  foot  deformities  is 
unknown,  though  they  often  are  attributed  to  malj)osition  in  the 
uterus.  The  hands  sometimes  are  the 
seat  of  similar  deformities  {Cluh  Hands). 
The  deformity  may  affect  one  or  both 
feet.  There  are  several  distinct  types 
of  deformity,  though  usually  more  than 
one  is  present.  Talipes  Equinus  is 
"pointed  toe"  deformity  in  w'hich  the 
front  of  the  foot  is  depressed  and  the 
heel  elevated,  the  patient  walking  on 
the  toes,  as  a  horse,  whence  the  name. 
In  Talipes  Calcaneus  the  heel  is  de- 
pressed and  the  toes  elevated.  In 
Talipes  Varus  the  anterior  part  of  the 
foot  is  adducted,  and  the  foot  is  inverted 
(supinated);  the  inner  border  of  the 
sole  is  shortened  and  elcA'ated,  and  the 
patient  walks  on  the  outer  border.  In 
Talipes  Valgus  the  anterior  part  of  the 
foot  is  abducted,  the  foot  is  everted 
and  pronated,  the  sole  is  flat,  and  the 
inner  border  of  the  foot  is  convex.  In 
Talipes  Cams  or  Arcuatus  ("hollow 
foot")  the  arch  of  the  foot  is  high,  and 
the  foot  is  shortened  antero-posteri- 
orly,  without  being  either  pronated  or 
supinated. 

At  birth  there  seldom  is  appreciable  bony  deformity,  but  contrac- 
tures of  tendons  and  ligaments  as  well  as  of  the  skin  and  subcutaneous 
tissues  are  present.  If  the  deformity  is  not  overcome  while  the  bones 
are  soft,  these  will  become  deformed,  adapting  their  form  to  the 
altered  function  required  by  weight-bearing  and  locomotion. 

Equino-varus.  —  The  most  frequent  combination  of  congenital 
deformities  is  that  of  equimis  and  tarns,  forming  the  ordinary  "club- 
foot" (Fig.  54S);  there  often  is  slight  cams  as  well.  The  feet  turn 
in,  the  soles  face  each  other,  the  tibial  border  of  the  sole  is  concave 
and  shortened,  and  the  heel  is  elevated.  There  is  no  natural  ten- 
dency for  the  deformity  to  correct  itself;  on  the  contrary,  if  patients 


Fig.  547.  —  Congenital  talipes 
equinus,  with  slight  cavus  deform- 
ity in  a  boy  of  thirteen  years. 
Orthopaedic  Hospital. 


51G 


ORTHOPEDIC  SURGERY 


Fig.  548. — Congenital  equino -varus    (double),  age 
seven  months.  (See  Fig.  549.)  Orthopiedie  Hospital. 


are  iie<i;lec'te(l  and  allowed  to  walk,  the  deformity  constantly  increases 
until  in  extreme  cases  they  may  have  to  walk  on  the  dorsum  of  the 
foot  (Fig.  549).  The  tibialis  anticus  and  posticus  are  short,  and  keep 
the  foot  inverted;  the  tendo  Achillis  raises  the  heel;  the  i)lantar  fascia 

is  contracted  and  arches 
the  foot,  and  the  flexors 
of  the  toes  aid  in  causing 
cavus  deformity.  The  cal- 
caneum  long  remains  small 
and  ill-formed,  and  the  calf 
muscles  are  poorly  devel- 
oped, because  of  disuse; 
and  the  extensors  of  the 
toes  and  the  peronei,  which 
work  at  marked  disadvan- 
tage, are  weak  and  totally 
unable  to  overcome  the 
deformity. 

Treatment. — In  earliest  infancy  manual  correction  alone  may  suffice, 
if  it  is  applied  intelligently  and  at  least  twice  daily.  Holding  the 
leg  bones  at  the  malleoli  in  one  hand,  the  other  hand  forcibly  abducts 
the  foot,  so  as  to  stretch  the  shortened  tissues  on  the  inner  side  of  the 
sole.  This  is  repeated  from  ten  to  twenty  times,  morning  and  night. 
When  the  aflduction  can  be  over- 
come, and  the  foot  brought  into  a 
straight  line  with  the  leg,  but  not 
before,  attempts  are  made  to  bring 
the  heel  down  by  dorsi-flexing  the 
foot  in  the  sagittal  plane.  By  no 
means  should  the  tendon  of  Achilles 
be  divided  so  long  as  there  remains 
the  slightest  tendency  to  varus; 
without  the  calcaneum  as  a  fixed 
point  (made  so  by  the  attachment 
of  the  Achilles  tendon)  it  is  impos- 
sible to  overcome  by  manipulation 
the  adduction  of  the  foot.  From  the 
age  of  a  few  weeks  until  the  child 
begins  to  stand,  the  foot  should  be 
held  in  the  best  position  obtainable 
at  each  manipulation  by  being  ban- 
daged to  a  posterior  right-angled 
splint,  or  in  plaster  of  Paris.  If  plas- 
ter of  Paris  is  used,  the  case  should 

be  renewed  every  two  or  three  weeks  and  the  foot  put  up  again  in  the 

improved  position  secured  by  renewed  manipulation.     Sometimes  it  is 

necessary  to  anesthetize  the  baby  to  apply  manipulation  effectively. 

If  this  treatment  is  faithfully  carried  out  there  are  very  few  cases 


Fig.  549. — Inveterate  varus.  Same 
imtient  as  Fig.  548,  three  years  later. 
Has  received  no  treatment;  walks  on  the 
dorsum  of  his  feet.  Orthopaedic  Hospital. 


CONGENITAL   TALIPES 


517 


of  cliil)  foot  in  whicli  the  feet  will  not  be  in  sufficiently  ^ood  position 
for  weight-hearing-  when  tlie  age  for  walking  arrives.  At  this  stage 
braces  may  be  applied,  to  be  worn  night  as  well  as  day,  but  removed 
daily  for  washing  and  manipulation;  and  these  must  be  continued 
until  there  is  no  further  tendency  to  relapse.  The  main  factors  in  such 
apparatus  are  a  strong  laced  shoe,  open  to  the  toe,  so  that  the  foot 
can  be  inserted  easily;  an  instep  strap  to  hold  the  foot  against  the 
sole,  and  keep  the  heel  from  rising;  side  irons  to  prevent  inversion  of 
the  foot;  and  an  elastic  strap  from  the  outer  side  of  the  foot  to  the 
outer  side  iron,  to  keep  the  ankle  dorsi-flexed  and  the  foot  everted. 
Apparatus  is  not  designed  to  overcome  deformity,  but  acts  merely  as 
do  splints  in  the  case  of  fractured  bones,  to  maintain  proper  position 
after  this  has  been  secured  })v  other  means.     These  braces  (as  all 


h'lG.  5.30.  —  Double  eciumo-vuriiii 
(congenital).  Age  .seven  years.  Re- 
lapsed case,  from  neglect  of  treatment. 
Orthopiedic  Hosijital. 


Fig.  551. — Relapsed  varus.  Rear  view 
of  patient  in  Fig.  550.  (See  Fig.  556.) 
OrthopEedic  Hospital. 


other  orthopedic  apparatus)  will  require  constant  oversight  and 
adjustment,  and  this  must  not  be  shirked  by  the  surgeon  who  under- 
takes the  treatment  of  such  cases.  Braces  present  the  great  advan- 
tage over  gypsum  that  they  permit  muscular  action,  and  so  favor 
development  of  the  hmb.  Usually  they  should  extend  to  mid-thigh, 
for  greater  security;  and  where  internal  rotation  of  the  foot  is  per- 
sistent, it  may  be  necessary  to  add  a  pelvic  band,  so  as  to  ha^'e  some 
fixed  point  by  which  to  evert  the  entire  lower  extremity. 

In  cases  in  which  proper  treatment  has  been  neglected,  and  in 
relapsed  cases  (Figs.  550  and  551),  mere  manipulation  usually  is 
powerless  to  overcome  the  deformity.  Here  the  patient  must  be 
anesthetized,  and  more  forcible  stretching  done,  as  indicated  in  the 
accompanying  illustrations  (Figs.  552,  553,  554  and  555).    The  foot  is 


518 


ORTHOPEDIC  SURGERY 


Fig.  552. — Club-foot  wedge  in  use,  ovtrcominL:  \  .uu-.     Orthopaedic  Hospital. 


Fig.  554. — Use  of  G.  G.  Davis's  lever  to  stretch  tendo  Achillis.   Orthopsedic  Hospital. 


CONGKN 1 TA  L   TA  L 1  PES 


519 


dressed  in  over-corrected  position  in  plaster  of  I'aris  and   the  patient 
stays  in  hed  several  days  after  the  oj)erati()n,  and  for  the  first  twenty- 


^rJ^^BIP^ 

^■^^^^^^^  -         ..!«i^^^B 

^^^Lf^sea^sfaaaJkesmimima^r.  -  ■ 

Fig.  555. — G.  G.  Davis's  ^•aI■us  niafliinc  in  use.     ( )rth()ija'dic  H(jspital. 

four  liours  the  foot  is  kept  elevated  to  prevent  edema.    Walking  in 
the  gypsum  case  is  then  allowed.    If  the  stretching  {redressement  force) 

is  skilfully  done,  evil  consequences 
are  very  unusual,  though  rarely  a 
superficial  slough  may  form  o^•er  the 
dorsum  of  the  foot.  The  plantar 
fascia  often  is  tense,  and  usually 
should  be  divided;  but  tenotomy'  of 
the  tendo  Achillis  or  other  tendons 
seldom  is  advisable.  Tenotomy  usu- 
ally is  done  by  the  subcutaneous 
method  (Stromeyer,  1831) :  a  punc- 
ture is  made  by  a  sharp-pointed 
tenotome  (Fig.  557)  just  to  one  side 
of  the  tense  tendon  and  where  it 
is  most  accessible;  a  blunt-pointed 
tenotome  is  then  inserted  beneath 
the  tendon,  and  while  this  is  kept 
taut,  it  is  divided  from  within  out- 


FiG.  556.  —  Double  ccjuino-varus 
after  use  of  instruments  sliown  in  Figs. 
552  to  554.  Same  patient  as  Figs.  550 
and  551.     Orthopaedic  Hospital. 


Fig.  557. 


-Sharp  and  blunt-pointed 
tenotomes. 


ward  by  a  gentle  sawing  motion;   any  oozing  of   blood  is  checked 
by  pressure  and  an  aseptic  dressing  appliefl  with  the  limb  as  much 


520 


ORTHOPEDIC  SURGERY 


over-corrected  in  position  as  is  possible;  and  this  position  is  maintained 
by  a  fixed  dressing;  for  four  to  six  weeks.  Tlie  tendo  Achillis  is  divided 
ai)()ut  an  inch  above  its  insertion;  the  tibialis  anticus  below  the  annular 
ligament;  the  tibialis  posticus  between  the  internal  malleolus  and  its 


Fig.  558. — Double  congenital  talipes  valgus.     Age  t\v(j  and  a  half  years. 
Orthopedic  Hospital. 

point  of  insertion;  and  the  peroneal  tendons  behind  and  above  the 
external  malleolus. 

In  cases  in  which  bony  deformity  has  developed,  which  cannot  be 
overcome  by  forcible  manipulation  as  above  indicated,  it  may  be 

necessarv  to  do  some  formal  cut- 


ting operation.  Phelps 
divided  all  the  structures  (skin, 
muscles,  tendons,  ligaments)  on 
the  contracted  side,  in  the  same 
plane,  until  the  astragalo-scaphoid 
joint  was  widely  opened,  and 
dressed  the  foot  in  over-corrected 
position,  packing  the  wound  with 
gauze.  While  this  is  efficient  in 
overcoming  deformity  at  the  time, 
relapses  are  not  unknown,  and  the 
foot  is  stiff  and  functionally  im- 
paired at  the  best.  Ogston  (iS92), 
^lenciere  of  Uheims,  and  Barlow, 
in  the  case  of  very  young  children, 
have  adopted  a  method  called  by 
^lenc'iere  "  modelage  parevidemeiH;" 
this  consists  in  excavating  all  but 
a  shell  of  the  calcis,  astragalus  and 
cuboid,  by  means  of  a  small  curette, 
and  then  forcibly  correcting  the  deformity,  a  procedure  which  is 
rendered  easy  by  the  temporary  weakness  produced  in  the  bones.  In 
most  cases  of  bony  deformity  in  children  or  adults,  the  best  method 


Fig.  559. — Congenital  clul>feet  and 
contracture  of  knee.  Age  three  years. 
Episcopal  Hospital. 


PA  RA  L  Y TIC  DEFOIi.\ffTII'JS 


521 


of  ()V(*r('()niiii<;  tlio  doformity  is  to  do  cuneiform  tarsectomy,  or  wedj^e- 
sliapcd  ri'soctioii  ol'  the  tarsus  (\{.  I)a\\-,  lSSlj:iii  this  operation  u 
wod^e  of  l)one  (regardless  of  tlie  outlines  of  the  individual  bones), 
witii  its  base  on  tiie  dorsum  and  its  apex  on  the  sole,  is  removed  from 
across  the  tarsus;  the  portion  excised  hv'iu^  sufhciently  lar<re  to  allow 
over-correction  of  the  deformity.  Astragalectomy,  which  is  preferred 
by  many  surgeons,  is  more  difHcult  of  execution,  and  leaves  a  less 
shapel}'  foot  than  does  cuneiform  tarsectomy. 

Other  forms  of  congenital  talipes  (Fig.  ooS),  as  well  as  club-hand, 
contracted  knee  (Fig.  'mI)),  etc.,  are  so  rare  that  it  seems  unnecessary 
to  discuss  them  here,  as  the  princi|)les  of  treatment  are  the  same  as 
in  equino-\arus. 


PARALYTIC   DEFORMITIES. 

Acute  Anterior  Poliomyelitis.  —Paralytic  Talipes.— ]\Iost  of  the  para- 
lytic deformities  which  re(|uire  orthopedic  treatment  are  the  result 
of  "infantile  paralysis,"  though 
cases  occasionally  are  encountered 
the  eflFect  of  cerebrospinal  menin- 
gitis, diphtheria,  or  other  rarer 
infections.  The  vast  majority  of 
cases  of  infantile  palsy  involve  one 
or  both  lower  extremities,  espe- 
cially the  feet.  The  extent  of  the 
paralysis  is  very  variable;  it  may 
affect  only  one  muscle  group,  or  a 
single  muscle ;  or  it  mav  affect  both 
lower  extremities  in  their  entirety, 
forcing  the  child  to  walk  on  his 
hands,  using  the  feet  merely  as 
props  (Fig.  5()0),  or  occasionally 
inducing  a  quadrupedal  gait;  or 
the  trunk  also  may  be  paralyzed, 
rendering  the  child  helpless.  In- 
fantile palsy  affecting  one  side  of 
the  back,  is  an  occasional  cause 
of  scoliosis  (Fig.  579).  In  some 
cases  there  is  only  slight  tendency 
to  contractures  of  the  unparalyzed 

muscles,  the  paralyzed  part  remaining  entirely  flaccid ;  while  in  others, 
contractures  are  an  early  and  prominent  symptom.  In  nearly  every 
case  deformity  eventually  develops. 

When  it  has  been  ascertained  that  paralysis  exists,  it  is  important 
to  institute  mechanical  treatment  at  once,  to  prevent,  so  far  as 
possible,  the  development  of  deformity,  and  to  encourage  return 
of  function.  Even  the  weight  of  the  bed-clothes  on  the  toes  may  be 
injurious,  predisposing  to  equinus  deformity.     The  foot  should  be 


Fig.  560. — Infantile  palsy  of  both  lower 
extremities.  Position  assumed  in  walk- 
ing on  hands.  Age  four  years.  Ortho- 
psedic  Hospital. 


522 


ORTHOPEDIC  SURGERY 


and   use 


supported  at  a  right  angle  with  the  leg,  and  the  knee  and  hip  should 
be  kept  fully  extended,  by  suitable  splints  or  apparatus.  Meanwhile, 
massage  and  electric  treatment  (galvanism)  should  be  employed, 
of  the  limb  encouraged,  provided  that  proper  posture  is 
maintained.  Usually  after  a  month  or 
two  the  extent  of  the  paralysis  will  be 
fairly  well  defined,  but  under  conserva- 
tive measures,  further  improvement 
may  occur  for  two  or  three  years.  If 
proper  treatment  (orthopedic  support, 
massage,  electricity)  has  been  insti- 
tuted promptly,  and  faithfully  pur- 
sued, usually  there  will  be  no  further 
improvement  after  the  lapse  of  this 
time.  But  in  all  cases  where  such 
treatment  has  not  been  employed,  the 
surgeon  should  delay  resort  to  opera- 
tive methods  until  trial  has  been  made 
of  mechanical  support,  massage,  etc., 
for  at  least  two  years. 

If  deformity  develops  from  neglect 
of,  or  in  spite  of.  proper  support  by 
apparatus,  various  forms  of  paralytic 
talipes  may  be  present.  These  are  dis- 
tinguished from  the 
congenital  talipes  by 
their  being  acquired, 
the  second  or  third  year  of,  life,  as  the 
result  of  an  acute,  even  if  slight,  febrile  attack,  after  which  the  child 
began  to  limp;  by  their  flaccid  character,  some  muscles  being  notice- 
ably paralyzed,  while  others  by  overaction  cause  persistent  deviation 
of  the  foot;  by  reactions  of  degeneration  in  the  paralyzed  muscles 
when  their  electrical  con- 
tractility is  investigated 
(these  never  exist  in  con- 
genital talipes);  and  by 
marked  atrophy  of  the 
parah'zed  limb. 

The  most  frequent  de- 
formity is  equino-var  us,  due 
to  paralysis  of  the  peroneal 
muscles,  often  associated 
with  loss  of  power  in  the 
extensor  longus  digitorum 
and  extensor  longus  hallucis;  the  tibialis  anticus  and  posticus  act 
as  strong  inverters  of  the  foot,  and  the  unopposed  flexors  and 
calf  muscles  maintain  foot-drop  (Fig.  561),  producing  a  potential 
equinus  which   if  long  uncorrected  may  become   a  fixed  deformity 


Fig.  561. — Paralytic  foot-drop,  in 
a  girl  of  fourteen  years.  OrthopEedic 
Hospital. 


deformities  of 
the  history  of 
usually  during 


Fig.  .562. — Paralytic  equinus,  age  twenty  years, 
deformity  growing  steadily  worse  since  childhood. 
Orthopaedic  Hospital. 


PARALYTIC  DEFORMITIES 


523 


(Fi^'.  oC)^).  Ill  otlier  cases  there  is  no  marked  coiitraeture  of  the 
acti\e  muscles,  but  owing  to  the  paralysis,  tlie  foot  easily  turns  into 
a  position  of  extreme  deformity  (Fig.  oOlJ),  rendering  locomotion 
almost  impossible  without  apparatus.     P(irali/iir  Cdlcdiiciis  (l''ig.  .')(').")) 


Fici.  5G.3. — Paralytic  varus  before 
operation.  Age  fifteen  jears;  dura- 
tion eight  years.  (See  Fig.  564.) 
Orthopaedic  Hospital. 


Fig.  56-1. — Patient  shown  in  Fig.  503,  after 
transplantation  of  tibialis  anticus  to  base 
of  fifth  metatarsal  bone.  Orthopaedic  Hos- 
pital. 


Fig.  565.— Paralytic  calcaneus,  showing  attitude  assumed  in  walking.  Aged  twelve 
years;  duration  eight  years.  Left  foot  assumed  similar  attitude  as  soon  as  any  attempt 
at  motion  was  made,  but  patient  could  not  balance  himself  long  enough  with  both  feet 
in  action  for  a  photograph  to  be  taken.     (See  also  Fig  566.)    Orthopaedic  Hospital. 


524 


ORTHOPEDIC  SURGERY 


is  clue  to  paralysis  of  the  calf  muscles;  the  unopposed  extensors  cause 
the  toes  to  fly  into  the  air  at  each  step;  sometimes  there  is  dislocation 

of  the  peroneal  tendons  anterior  to  the 
external  malleolus.  Calcaneus  deformity 
usually  is  combined  with  marked  cavus 
(P^ig.  566),  though  this  may  exist  alone, 
from  contracture  of  the  plantar  fascia 
and  extensors  of  the  toes,  when  the  short 
foot  muscles  (interossei  and  lumbricals) 
have  been  paralyzed  (Fig.  571).  Para- 
lytic Valgus  (Fig.  569)  is  much  more 
common  than  a  similar  congenital  de- 
formity; usually  the  two  tibial  muscles 
are  paralyzed,  and  sometimes  the  flexors 
of  the  toes  as  well.  Usually  the  peronei 
are  cbntracted. 

When  it  has  been  ascertained  that  no 
further  improvement  is  to  be  expected 
without  operation,  the  aim  of  the  sur- 
geon should  be  to  devise  some    means 
Pi,;  56(i.— Paralytic  calcaneus,      ''>'  ^vhich  apparatus  may  be  discarded. 
showing  secondary  cavus,  when      \Yhenever  there  are  a  sufficient  number 

toes    were   forcibly  flexed.     Same  c  i        1^1  1        !>        j.\  -^  • 

patient  as  Fig.  565.  ot  healthy  muscies  tor  the  purpose,  it  is 


Fig.  567. — Paralytic  calcaneus  after  transplantation  of  the  peronei  and  tibialis 
posticus  into  the  caicaneum,  showing  power  of  raising  the  heel.  (See  Figs.  565.  566,  and 
568.)     Orthopaedic  Hospital. 


PARMA  TIC  DEFORMITIES  525 

possible,  \)\  cliaii^iiig  tlie  points  of  insertion  of  one  or  more,  so  to  dis- 
tribute the  muscular  power  wliieh  remains  as  to  secure  to  the  patient 
a  well  balanced  foot.  This  o])erati(m  is  known  as  Tendon  Transplanta- 
tion. It  seldom  isadvisable  to  employ  it  before  the  age  of  six  years,  since 
before  this  age  it  is  very  difficult  to  be  certain  which  muscles  are 
functionally  active,  because  this  is  a  point  ascertained  much  more 
accurately  by  clinical  observation  than  by  investigation  of  the  elec- 
trical reactions.  IJefore  tendon  transplantation  is  attempted,  it  is 
important  to  overcome  all  deformity,  and  this  may  require  repeated 
manipulation  under  an  anesthetic,  red ressement  force  (as  in  congenital 
talipes,  p.  518),  or  even  tenotomies;  only  when  the  foot  can  be  held 


Fig.  568. — Paralytic  calcaneus  two  months  after  tendon  transplantation. 
(See  Figs.  565,  566,  and  567.)     Orthopaedic  Hospital. 

in  the  over-corrected  position  by  the  pressure  of  one  finger,  will  it 
be  safe  to  resort  to  operation.  The  best  method  of  tendon  trans- 
plantation is  the  periosteal  insertion  of  Lange  (1898);  this  may  be 
succinctly  described  by  a  concrete  example,  namely,  the  transplan- 
tation of  the  tibialis  anticus  to  the  base  of  the  fifth  metatarsal 
bone,  for  the  relief  of  ^'arus  due  to  paralysis  of  the  peroneal  muscles. 
Under  Esmarch  anemia  the  tibialis  anticus  is  divided  at  its  insertion, 
and  is  drawn  out  of  its  sheath  through  a  second  incision  made  over 
its  course  above  the  annular  ligament;  a  subcutaneous  channel  is 
then  burrowed  from  above  the  annular  ligament  to  the  tuberosity 
of  the  fifth  metatarsal  bone,  and  through  a  third  incision  at  the 


526 


ORTHOPEDIC  SURGERY 


latter  })()iiit  tlie  tendon  of  the  tibialis  anticus  is  drawn  down,  and  under 
the  utmost  possihk-  tension  is  sutured  to  the  periosteum  by  several 


Fig.  569. — Paralytic  valgus,  age  seven 
years;  treated  by  tendon  transplantation. 
(See  Fig.  570.)     Orthopsedie  Hospital. 


Fig.  570. — Patient  .shown  in  Fig.  569. 
After  transplantation  of  peroneus  brevis 
and  tertius  to  insertion  of  tibialis  anticus. 


mattress  sutures  of  strong  chromic  catgut.    The  foot  is  immobilized 
in  over-corrected  position  (valgus),  in  gypsum,  for  eight  weeks;  func- 
tion   is    then    gradually     resumed. 

^ 1     The    tibialis    antictis     being    now 

^^^^^  -^/tT      >v^       inserted  on   the   outer   side  of   the 

^^^Er  "  7  J      ^^"^^  ^^^^  ^*^"^  ^^  ^"  everter,  largely 

^^^1  A  fl      replacing    the    paralyzed     peronei, 

^^^H  I      ^^A  1      and  rendering   the    further  use  of 

^^^H  ^^^^^B  I      apparatus 

^^^H         ^H^^H  I  In  similar  manner,  for  other  de- 

^^^H        ^^^^^^B  I      formities,    ^'arious    other    tendons 

^^^H        ^^^^^^H         fl      may  be    transplanted,   as    will  oc- 
^^^H        ^^^^^^H        ■  to  the  mind  of  any  ingenious 

^^^V        ^^^^^^B        H      surgeon.     For  paralytic  valgus  it  is 
^^^  ^^^^^V        V      best    to    transplant    the    extensor 

B^     ^^^^^^^^m         fl      longus  hallucis  to  the  insertion  of 
^^j^^^^^^^^^^r  fl      the  tibialis  anticus;  when  the  exten- 

^^^^^^^^^^^^m  ^M  longus  hallucis     paralyzed 

^^^^^^^^^^^^■■■i^HH      ferred  to  the  insertion  of   the  tibi- 


FiG.   571.  — Paralytic    cavus,   age  alis  anticus   (Figs.  5G9  and  570);  or 

eleven    years    showing   over-action    of  if  the    extenSOr    longUS    digitorum   is 
the    extensor  longus    hallucis.     Ortho-  ..  j,        t   ,    i  i      p    .i        j.m  •    i- 

pffidic  Hospital.  active,  the  (h.sinl  end  ot  the  tibiaUs 


I'A  UAL  YTK  ■   DKI'OUMrjJI'JS 


527 


aiiticus  (<livi(le<l  al)(>\e  the  annular  li^anicnt)  may  be  sutured  to  this 
healthy  tendon.  For  paralytic  cavus,  the  extensor  lon^'us  lialiucis, 
which  is  usually  the  deforming  factor  (Fig.  571),  may  be  attached  to 
the  head  of  the  first  metatarsal.  For  paralytic  calcaneus  the  peronei 
and  tibialis  posticus  may  be  traiisi)lanted  into  the  insertion  of  the 
tcndo  Achillis  (Figs.  5(')r)  to  5()S).  For  paralysis  of  the  quadriceps 
femoris  one  or  more  of  the  hamstrings  may  be  transplanted  into  the 
patella;  and  for  paralysis  of  the  internal  rotators  of  the  thigh,  the 
tensor  fascijie  femoris  may  be  transplanted  into  the  great  trochanter 
(G.  G.  Davis.  1011). 


Fic 


572. — Paralj-tic  flail-foot,  age  eighteen  j-ears;  duration  fourteen  years. 
(See  Fig.  573.)     Orthopaedic  Hospital. 


In  many  cases  it  is  possible  by  shortening  paralyzed  tendons  to 
enable  them  to  act  as  ligaments  in  maintaining  better  position,  or 
when  slight  power  remains,  to  enable  them  to  use  it  to  better  advan- 
tage. If  a  healthy  tendon  is  too  short  to  be  available  for  purposes 
of  transplantation,  silk  strands  may  be  attached  to  its  end  in  an  imbri- 
cated manner,  and  the  tendon  thus  lengthened  the  required  amount. 

Nerve  Anastomosis  has  been  employed  in  some  cases  of  paralytic 
deformities  of  the  feet,  but  not  with  much  success.  It  should  be 
reserved  for  those  cases  in  which  the  entire  distribution  of  one  nerve 
is  })aralyzed,  but  in  which  the  entire  flistril)ution  of  a  neighboring 
nerve  is  intact.  I  employed  it  in  one  case  in  which  the  entire  distri- 
bution of  the  anterior  tibial  nerve  was  paralyzed,  but  in  which  that 
of  the  musculo-cutaneous  was  unaffected,  anastomosing  the  peripheral 


528  ORTHOPEDIC  SURGERY 

end  of  the  anterior  tibial  into  the  musculo-cutaneous;  but  no  power 
was  re«;aine(l. 

Arthrodesis. — When  so  many  muscles  are  paralyzed  that  none  are 
available  for  transplantation,  it  is  possible  to  convert  a  "dangle-foot" 
with  flail-joints  (Fig.  572)  into  a  firm  and  useful  support  by  pro- 
ducing an  artificial  ankylosis  (Fig.  573).  This  operation,  known  as 
arthrodesis  (Fig.  574),  should  not  be  undertaken  before  the  age  of 
nine  years  at  least,  since  the  bones  of  younger  patients  are  still  too 
cartilaginous  for  firm  union  to  follow  a  joint  resection.  For  "foot- 
drop,"  arthrodesis  of  the  ankle-joint  is  done:  through  a  small  trans- 
verse incision  over  the  front  of  the  joint,  displacing  the  tendons,  the 
articulating  surfaces  of  the  astragalus,  tibia,  and  fibula  are  removed.^ 


Fig.  573. — Result  of  arthrodesis  of  ankle,  and  subastragalar  joints  for  paralytic 
flail-foot  (Fig.  572).     (See  Fig.  574.)     Orthopedic  Hospital. 

For  lateral  mobility,  subastragalar  arthrodesis  is  done;  in  eight  cases 
I  have  found  a  single  external  incision,  above  the  peroneal  tendons, 
sufficient  to  remove  the  articulating  surfaces  of  astragalus  and  calca- 
neum,  as  well  as  those  of  astragalus  and  scaphoid  (Fig.  165).  The 
wounds  are  closed  without  drainage,  and  the  foot  is  fixed  in  gypsum 
for  eight  weeks,  when  walking  may  be  resumed;  but  a  light  brace 
should  be  worn  for  a  few  months  more. 

1  To  secure  closer  apposition,  Goldthwait  (1908)  advises  osteotomy  of  the  fibula 
just  above  the  malleolus,  with  inward  displacement  of  this  process  against  the 
astragalus. 


I'ARALvric  1)1<:f()I{Mitu<:s  .)2<) 

In  somr  cases  hoforr  the  ])atioiit  is  old  ciioukIi  to  have  arthrodesis 
(hme,  a  Ihiil-joint  may  he  rcMidered  more  or  less  firm  l)y  the  insertion 
thron^h  the  hones  of  sIvdikj  .sill:  .siituirs,  to  act  <i.s  lif/ainntt.s'  (Lan^'e, 

19l)o). 


Fig.  574.- 


-Rcsult  of  arthrodesis  of  ankle  and  subastragalar  joints. 
572  and  573.)      Orthopa?dic  Hospital. 


(See  Figs. 


Infantile  Paralysis  of  the  Up- 
per Extremity  (Fig.  575),  much 
rarer  than  paralytic  affections 
of  the  lower  limbs,  is  treated 
on  the  same  general  princi- 
ples. Transplantation  of  mus- 
cles has  been  done  chiefly  at 
the  shoulder  where  a  portion 
of  the  trapezius  or  of  the  pec- 
toral is  major  has  been  used 
to  supplement  the  deltoid. 
Nerve  anastomosis  has  given 
no  better  results  than  in  the 
leg. 

34 


Fig.  575. — Infantile  palsy  of  right  arm. 
Children's  Hospital. 


530 


ORTHOPEDIC  SURGERY 


Cerebral  Palsies. — These  result  from  cortical  or  meningeal  hemor- 
rhages, or  from  congenital  defects,  such  as  porencephalon.  Spas- 
ticity is  their  main  characteristic,  and  by  this  factor  it  usually  is 
possible  to  distinguish  them  from  infantile  paralysis,  which  is 
flaccid.  In  children  they  usually  occur  from  injury  at  birth,  and 
there  often  is  mental  impairment  (p.  576),  In  adults  they  may 
follow  cranial  injuries,  apoplexy,  etc.  The  paralysis  is  hemiplegic, 
paraplegic,  diplegic,  or  monoplegic,  according  to  the  site  of  the  cere- 
bral lesion.  The  hemiplegic  form  is  most  frequent,  the  paraplegic 
next,  while  the  monoplegic  or  diplegic  types  are  quite  rare.  The 
flexor  muscles  are  stronger  than  the  extensors,  and  the  deformity  is 

quite  characteristic:  the  arm  is  adducted, 
the  elbow  flexed,  the  forearm  pronated,  the 
wrist  flexed  and  the  hand  clasped  tight;  the 
hip  is  flexed  and  adducted,  the  knee  slightly 
flexed,  and  the  foot  in  the  equino-varus 
position,  there  being  a  tendency  to  walk 
on  the  toes  (Fig.  576).  By  gradual  steady 
pressure  it  usually  is  possible  to  correct 
these  contractures,  but  as  soon  as  pressure 
is  released  they  recur,  the  patient  having 
very  little  if  any  voluntary  control  of  the 
aft'ected  limbs.  In  the  course  of  time  the 
deformity  becomes  permanent,  unless  mal- 
])osition  is  prevented  by  orthopedic  means. 
Treatment. — The  treatment  consists  in 
the  use  of  massage  and  manipulation  to 
prevent  the  contractures  from  becoming 
permanent.  Malposition  should  be  pre- 
vented by  splints  or  braces.  Tenotomy 
will  improve  position  temporarily,  but 
relapses  are  common.  A  longer  inter- 
mission before  relapse,  and  better  prospects 
of  permanent  functional  improvement  are 
oft'ered  by  intra-perineural  ncuroiomy  after 
the  method  of  Xutt  (1909):  the  nerves 
supplying  the  spastic  muscles  are  di^'ided  and  at  once  reunited 
by  suture;  temporary  paralysis  of  all  the  spastic  muscles  follows, 
injurious  peripheral  impulses  are  abolished;  and  return  of  power  to 
the  muscles  paralyzed  by  the  neurotomy  is  so  slow  that  the  weaker 
antagonistic  muscles  are  given  a  chance  to  recuperate.  P^orster 
(1908)  has  practised  intradural  division  of  the  sensory  nerve  roots 
{Rhizotomy)  supplying  the  affected  extremity,  but  the  operation 
is  dangerous  and  the  results  very  uncertain.  Schwab  and 
Allison  (1909)  have  used  intraneural  alcohol  injections.  In  most 
cases  the  disability  is  lasting,  and  no  form  of  treatment  is  "of 
much  avail. 


Fig.  576. — Infantile  spastic 
paraplegia,  age  three  years. 
Attitude  in  attempting  to 
walk.     Orthopaedic  Hospital. 


LATERAL  CL'RVATl'HE  OF  THE  SPINE  oM 

LATERAL  CURVATURE  OF  THE  SPINE. 

Lateral  Curvature  of  the  Spine,  or  Scoliosis,  is  an  aH'cction  of  cliild- 
liood.  It  is  coinoiiii'iit  to  <listiiij,niisli  hotwceii  functional  or  })osiiir(d 
lateral  curvature  and  true  orf/auic  or  structural  .scoliosis.  Tlie  former 
is  due  sinij)ly  to  malposition,  and  tiiere  is  a  general  (sinj^ie)  cnrAature 
of  the  spinal  eolunm,  usually  eonvex  to  the  left.  Hound  shoulders 
often  eoexist.  If  neglected,  these  children  may  develop  true  structural 
scoliosis,  as  the  hones  still  are  soft  and  their  shape  is  readily  altered 
by  long  continued  uneciual  pressure.  The  diagnosis  of  postural 
lateral  curvature  is  easily  made  by  dropping  a  plumb-line  from  the 
vertebra  prominens,  and  noting  the  deviation  of  the  sj)inous  processes. 
The  child  may  be  brought  for  examination  on  account  of  stooping, 
round  shoulders,  or  general  relaxation  of  the  joints.  Proper  gymnas- 
tics, attention  to  hygiene,  manner  of  supporting  the  clothing,  etc., 
usually  effect  a  cure  in  from  one  to  two  years.  The  clothing  should 
not  be  supported  by  the  points  of  the  shoulders,  but  as  far  as  possible 
from  the  ])elvis,  or  from  the  slope  of  the  neck;  any  ordinary  gym- 
nastic and  calisthenic  exercises  are  efficient;  over-study  and  tire  should 
be  avoided,  and  an  active  out-of-door  life  encouraged. 

In  organic  or  structural  scoliosis  there  is,  in  addition  to  lateral  devia- 
tion of  the  spinal  column  (Fig.  577),  also  rotation  of  the  bodies  of  the 
vertebrae,  the  transverse  processes  of  the  vertebrae  rotating  backward 
on  the  convexity  of  the  curve,  and  forward  on  its  concavity.  This 
rotation  is  best  appreciated  by  having  the  patient  bend  the  body 
horizontally  from  the  hips  (Fig.  578). 

Scoliosis  may  be  due  to  a  number  of  causes:  (1)  It  may  develop, 
as  already  mentioned,  as  a  sequel  of  jwstural  lateral  curvature;  this 
probably  is  the  most  frequent  cause.  Sometimes  it  is  convenient  to 
recognize  as  a  predisposing  cause,  in  cases  beginning  this  way,  a 
rachitic  or  other  dystrophic  softening  of  the  bones,  to  account  for  the 
rapidity  with  which  structural  changes  occur  in  the  spinal  column. 
(2)  Congenital  anomalies  of  the  spine  (studied  at  length  by  jNIouchet 
and  Rouget  in  1910);  there  may  be  a  supernumerary  wedge-shaped 
vertebra;  or  a  portion  of  one  or  more  vertebrae,  with  or  without  their 
attached  ribs,  may  be  absent.  The  deformity  in  these  cases  is  recog- 
nized in  early  infancy,  anfl  the  bony  lesion  usually  can  be  detected 
in  a  skiagraph.  (3)  Infantile  paralysis  or  other  muscular  lesion, 
allowing  unopposed  contraction  of  the  muscles  on  the  unaffected  side 
(Fig.  579),  is  a  rather  unusual  cause.  (4)  Empyema,  causing  collapse 
of  the  thorax  on  the  afi'ected  side,  is  a  frequent  cause  (Fig.  762).  (5) 
Torticollis,  and  other  deformities  of  neighboring  parts,  such  as  anky- 
losis of  the  hip  in  bad  position,  causing  tilting  of  the  pelvis,  should  also 
be  remembered  as  occasional  causes  of  this  deformity. 

In  most  cases,  as  already  mentioned,  the  deformity  arises  from 
faulty  attitudes  in  sitting,  standing,  sleeping,  etc.  It  develops  most 
frequently  between  six  and  ten  years  of  age,  and  occurs  in  girls  in  over 
75  per  cent,  of  cases.    The  child  carries  heavy  books  or  a  heavy  baby 


532 


ORTHOPEDIC  SURGERY 


habitually  on  one  arm;  sits  at  school  or  at  home  at  a  desk  or  table 
disproportionately  high,  requiring  habitual  undue  elevation  of  the 
right  shoulder;  one  leg  may  be  a  trifle  shorter  than  the  other,  or  the 
patient  may  sit  on  a  cushion  higher  on  one  side  than  on  the  other, 
inducing  obliquity  of  the  pelvis — in  short,  from  causes,  which  often 
cannot  be  defined,  the  patient  is  brought  to  the  surgeon  (unfortunately 
seldom  until  the  deformity  has  existed  for  some  years)  complaining 
of  asymmetry,  with  projection  of  one  shoulder  and  one  hip,  usually 
the  right.    Such  patients  should  be  examined  with  the  back  bare  from 


Fig.  577. — Scoliosis,  in  a  girl  of  sixteen 
years;  left  shoulder  droops,  right  thorax 
(convex  curve)  is  prominent.  (See  Fig. 
578.)     Orthopsedic  Hospital. 


Fig.  578. — Patient  in  Fig.  577,  stoop- 
ing to  show  posterior  rotation  at  the  side 
of  the  convexity  of  the  curve.  Ortho- 
paedic Hospital. 


neck  to  pelvis,  and  without  shoes  on  their  feet.  Even  if  no  asym- 
metry is  evident  at  a  glance,  it  is  extremely  likely  that  after  standing 
a  few  minutes  the  slouching  attitude  will  come  on,  and  reveal  the 
deformity.  In  the  immense  majority  of  cases  there  is  a  cur^•e  convex 
to  the  right  in  the  thoracic  region,  which  compensates  a  curve  convex 
to  the  left  in  the  luml)ar  region,  the  latter  being  regarded  as  the 
primary  curve.  (If  the  case  is  one  of  postural  scoliosis  only,  there 
seldom  is  more  than  one  curve,  which  usually  is  convex  to  the  left; 
placing  a  lift  under  the  left  foot  usually  causes  the  curve  to  flisappear.) 
The  line  of  the  waist  is  more  cut  in  on  the  left  side,  a  distinct  fold 


LATERAL  CURVATl'RE  OF  Till-:  SI'IXE 


533 


often  existing:;  (Fig.  577);  and  when  the  patient  st()()[)s  forward  at  the 
hips  the  right  thorax  becomes  prominent,  the  left  h)in  projects,  and 
the  riglit  loin  falls  away  (Fig.  57.S).  In  extreme  eases  the  anterior 
surface  of  the  thorax  is  deformed  also,  the  left  lower  rihs  hecoming 
very  prominent,  and  the  apex  of  the  right  lung  being  markedly  com- 
pressed; sometimes  the  liver  is  proptosed,  and  the  heart  displaced  to 
tFie  left.  Valvular  incomi)etency  is  frequent  in  cases  of  great 
deformity.  Besides  the  deformity, 
the  patient  complains  of  tiring  easily, 
of  weakness,  or  of  marked  disability. 

Diagnosis.-  In  cases  of  very  slight 
degree  it  is  didicult  sometimes  to  be 
certain  that  the  affection  is  scoliosis 
and  not  incipient  tuberculosis  of  the 
spine.  In  the  latter  condition  there 
may  be  lateral  deviation  of  the  spine 
without  any  kyphosis;  l)ut  the  lateral 
deviation  is  more  abrupt  than  tlic 
gentle  curve  of  scoliosis  (Fig.  639) ; 
there  is  painful  rigidity  of  the  spine  as 
detected  by  flexion,  hyperextension, 
and  lateral  bending;  there  usually  is 
tenderness  localized  to  the  seat  of 
disease;  there  may  be  constant,  slight, 
evening  rise  of  temperature;  and  the 
tuberculin  test  probably  will  be  posi- 
tive. A  skiagraph  may  reveal  a 
tuberculous  lesion;  but  in  cases  of 
scoliosis,  except  those  easily  recog- 
nized as  such  clinically,  will  show  no 
bony  change.  If  the  slightest  doubt  as 
to  the  nature  of  the  trouble  persists, 
treatment  for  Pott's  disease  (p.  609) 
should  be  instituted  until  its  absence 
is  proved. 

Treatment. — The  mildest  grades  of 
rotatory  scoliosis  may  be  overcome 
by  correction  of  habitual  malposi- 
tion and  special  gymnastic  exercises 

under  the  supervision  of  a  competent  orthopedic  surgeon.  The 
patient  should  sleep  on  a  hard,  flat  bed,  without  a  pillow,  and 
either  supine  or  prone;  she  should  spend  at  least  one  hour  each 
day  lying  flat  on  her  back  on  a  hard  level  couch  or  on  the  floor;  and 
should  give  up  habits  of  writing,  reading,  sewing,  etc.,  which  require 
a  cramped  posture.  Where  pain  or  disability  is  marked,  recumbent 
treatment,  with  head  and  foot  extension,  as  for  Pott's  disease  should 
be  instituted.  The  exercises  prescribed  for  scoliosis  cannot  be 
detailed  here ;  they  form  almost  a  sub-specialty  in  orthopedic  practice, 


Fig.  579. — Iiicipii'nt  scoliosis,  fol- 
lowing infantile  palsy  one  year  ago. 
Age  four  years.  Left  side  paralyzed. 
Orthopffidic  Hospital. 


534 


ORTHOPEDIC  SURGERY 


and  are  of  a  highly  technical  nature.  They  should  l)e  taken  daily 
(at  least  three  times  weekly)  for  from  one  to  three  hours  for  a  period 
of  nine  months  up  to  one  or  two  years.  It  is  folly  to  expect  per- 
manent improvement  sooner.  In  most  cases,  certainly  in  those  in 
which  noticeable  rotation  is  present,  the  patient  should  be  provided 
with  some  form  of  spinal  support;  for  all  severe  grades  of  deformity 
this  is  more  important  than  gymnastics,  as  it  is  futile  to  expect  to 
correct  bony  deformity  l)y  muscular  exercise.  As  H.  Bigg  (1905), 
L()\'ett  and  Seever  (1911),  and  other  recent  writers,  ])oint  out,  the 


Fig.  5MI.-— Plaster  nf  I'aris  jacket, 
applied  ueeordiiig  to  Abbott's  method 
for  the  treatment  of  scoliosis  (curve 
convex  to  right  in  thoracic  region). 
Large  window  cut  over  the  hollow  re- 
gion; the  left  shoulder  held  high  and 
forward;  the  right  shoulder  forced 
down  and  backward ;  the  pelvis  rotated 
forward  toward  the  right.  Orthopaedic 
Hospital. 


Fig.  581. — G.  G.  Davis's  brace  for  scoliosis. 
Orthopaedic  Hosi)ital. 


deformity  should  be  treated  on  the 
same  principles  that  guide  us  in 
treatment  of  other  bony  deformities, 
such  as  bow-legs  and  club  feet. 
The  most  efficient  corrective  apparatus  is  a  gypsum  jacket,  applied 
according  to  the  method  of  Abbott  (1912)  with  the  patient  lying 
supine  on  a  canvas  sling,  attached  at  each  end  to  a  special  frame. 
This  sling  is  cut  on  the  bias  at  one  end,  so  that  when  one  side  of  the 
sling  is  pulled  taut  the  other  is  relaxed.  The  taut  side  of  the  sling 
is  placed  under  the  prominent  side  of  the  thorax,  and  the  patient's 
head  and  thighs  are  thoroughly  flexed.  Then  bands  are  attached  to 
the  sides  of  the  frame  to  assist  over-correction  of  the  deformity,  and 
the  plaster  of  Paris  is  applied  and  moulded  carefully  to  the  body, 


STATIC   iJISOliDEh'S  OF   THE   lA'MBAU  Sl'lSE   AM)   I'KLVIS     o'.i') 

wliicli  lias  hei'ii  i)a(l(lo<l  witli  saddler's  felt  until  a])])r<).\i!nately  syrii- 
inetrical  in  t'orni.  When  the  plaster  lias  set,  larj^e  windows  are  cut  over 
the  eomi)resse(i  portions  of  the  thorax  (usually  over  the  left  scajjula 
and  lower  ribs  j)osteriorly,  and  the  right  mammary  region  anteriorly), 
and  the  pads  over  these  eompressed  portions  are  remove<l,  while 
increasing  ])ressure  is  brought  to  hear  on  the  ])rominent  portions  of 
the  thorax  hy  inserting,  at  intervals  of  a  few  (hiys,  broad  felt  pads 
between  the  thorax  and  jacket  (Fig.  580).  The  same  jacket  may  be 
worn  for  a  jH'riod  of  from  two  to  three  months.  A  new  jacket  then 
is  ai)plied  for  a  month  or  six  seeks  longer;  and  this  treatment  is  con- 
tinued until  ovcr-corirrtioti  of  the  deformity  has  been  obtained.  This 
form  of  treatment  is  the  most  efficient  yet  de\ised.  When  oxer- 
correction  has  been  secured  and  maintained  for  a  few  weeks,  sym- 
metry is  restored  by  gymnastics.  Treatment  by  gypsum  jackets  as 
formerly  ai)plied,  had  to  be  continued  indefinitely,  as  relapses  were 
frequent  and  very  prompt  after  apparently  complete  cures.  In 
Abbott's  method,  however,  the  reduction  of  deformity  is  reasonably 
rapid  and  if  over-correction  can  be  secured,  appears  to  be  lasting.  In 
less  severe  cases  removable  jackets  or  spinal  l)races  (Fig.  581)  may  be 
used,  constructed  to  act  on  the  same  principles  as  al)ove  described; 
but  they  are  less  efficient  than  irremovable  gypsum  jackets  even 
though  they  permit  coincident  use  of  gymnastics. 

STATIC  DISORDERS  OF  THE  LUMBAR  SPINE  AND  PELVIS. 

These  were  studied  in  1901  by  Goldthwait,  and  are  frequent  causes 
of  neurasthenia,  backache,  and  general  disability,  especially  in  women. 
After  childbirth,  or  during  convalescence  from  some  wasting  disease, 
or  simply  from  malnutrition,  overwork,  etc.,  the  tone  of  the  pelvic 
and  lumbar  muscles  is  lowered,  and  undue  strain  is  thrown  on  the 
ligaments.  Similar  symptoms  may  occur  after  prolonged  anesthesia, 
during  which  the  patient  has  lain  on  her  back  without  support  to  the 
lumbar  spine;  some  cases  of  "lumbago"  are  due  to  similar  conditions; 
and  most  patients  wuth  what  has  long  been  called  "neurotic  spine" 
have  some  static  disturbance  with  ligamentous  strain  as  the  basis  of 
their  trouble. 

The  most  frequent  condition  is  a  loss  of  the  normal  lumbar  lordosis; 
occasionally,  however,  somewhat  similar  symptoms  follow  increase 
of  the  lordosis,  caused  by  wearing  very  high-heeled  shoes,  by  anky- 
losis of  the  hip  in  a  flexed  position,  etc.  Flatness  of  the  back  often 
is  associated  with  weak  or  pronated  feet  (p.  547),  and  is  relieved  by 
treatment  of  the  foot  condition. 

The  normal  lumbar  lordosis  disappears  at  first  merely  when  the 
patient  is  supine;  later  it  is  absent  also  in  the  erect  posture.  The 
sacro-iliac  joints  and  symphysis  pubis  may  become  relaxed,  and  pain 
may  be  referred  down  the  sciatic  nerves;  while  at  each  step  the  patient 
may  feel  discomfort  and  may  obtain  relief  onl>-  by  lying  prone,  or 
supine  with  the  lumbar  spine  supported  by  a  pillow.    One  sacro-iliac 


536 


ORTHOPEDIC  SURGERY 


joint  frequently  is  more  relaxed  than  the  other.  By  placing  one  hand 
over  the  joint  while  the  other  palpates  the  symphysis  pul^is,  it  usually 
is  possible  to  detect  abnormal  mobility  as  the  patient  stands  first 
on  one  foot  then  on  the  other.  Or  with  the  patient  lying  prone, 
the  sacro-iliac  joints  may  be  made  to  move  by  hyperextending  the 
thighs. 

Treatment. — The  treatment  in  mild  cases  consists  in  massage  of 
the  lumbar  muscles,  with  gymnastic  exercises.  In  severe  cases  it  may 
be  necessary  to  put  the  patient  to  bed  with  weight  extension  to  the 
lower  extremities;  later  some  form  of  spinal  and  pelvic  support  must 
be  provided.    For   sacro-iliac  relaxation   the   application   of  a  firm 


Fiu.  582. — iSacio-iliae  sprain,  with  re- 
laxation (left  side).  For  eight  months 
pain  in  left  hip,  back,  and  down  sciatic. 
Diagnosed  Pott's  disease,  elsewhere.  Or- 
thopsedic  Hospital. 


Fig.  583. — Belt  for  sacro-iliac  relaxation. 
Orthoptedic  Hospital. 


pelvic  belt  between  trochanters  and  iliac  crests  often  is  all  that  is 
required  (Fig.  583).  Where  the  lumbar  spine  also  is  involved,  it  will 
be  necessary  to  support  this  also:  this  may  be  accomplished  by  the 
application  of  a  light  gypsum  jacket,  with  the  patient  lying  prone  on 
a  hammock,  as  in  Pott's  disease  (p.  611),  or  by  some  form  of  ortho- 
pedic corset  which  will  maintain  hyperextension  of  the  lumbar  spine. 
Spondylolisthesis  is  the  term  given  to  subluxation  of  the  last  lumbar 
vertebra  forward  on  the  sacrum;  occasionally  the  fourth  lumbar 
vertebra  is  displaced  forward  on  the  fifth.  The  affection  is  com- 
monest in  young  adult  females,  but  occurs  also  in  growing  girls  and 
in  youths  and  young  men.    There  is  a  depression  above  the  sacrum, 


DEFORMITIES  OF  THE  HEAD  AND  KECK 


bXi 


over  the  hist  hinihar  vertebra,  and  sometimes  a  promhienee  ean  be 
felt  above  tlie  sacral  eminence  by  a  finger  in  the  rectum  or  vagina. 
The  symptoms  and  treatment  are  nuich  the  same  as  for  static 
strains  of  the  lumbar  spine,  of  which,  indeed,  spondylolisthesis  may 
be  considered  the  terminal  stage. 


DEFORMITIES  OF  THE  HEAD  AND  NECK 

Torticollis,  Caput  Obstipum,  or  Wry-neck,  sometimes  is  (lue  to 
injury  at  birth,  rupturing  some  of  the  fibres  of  the  sternomastoid  or 
other  cervical  muscle.  It  is  uncertain  whether  the  cases  of  hematoma 
of  the  ster)w-mastoid  muscle  sometimes  seen  in  infants  are  a  result  of 
the  rupture  of  the  nuiscle  because  it  was  congenitally  short,  or  are 
themselves  the  cause  of  wry-neck  by  causing  subsequent  cicatricial 
contraction  of  the  muscle.  Often 
the  deformity  is  not  noticed  until 
the  child, is  several  months  old, 
and  then  it  is  difficult  to  be 
certain  whether  the  affection  is 
congenital  or  acquired.  As  a 
rule,  the  congenital  affection  is 
painless,  while  the  accjuired  form 
has  a  more  or  less  acute  onset. 
Torticollis  may  be  symptomatic 
of  certain  other  diseases,  as 
astigmatism,  or  cervical  Pott's 
disease  (p.  603),  fracture-dislo- 
cation of  the  cervical,  spine,  cer- 
vical rib,  cervical  adenitis  (Fig. 
584),  "rheumatic  stiff  neck," 
toothache,  ear-ache,  tonsillitis, 
or  other  affection  which  may 
irritate  the  spinal  accessory  or 
upper    cervical  nerves,  causing 

spasticity  of  the  muscles  concerned  in  the  production  of  the  deform- 
ity. These  are  especially  the  sternomastoid,  the  trapezius,  and  the 
scalenus  anticus,  especially  the  sterno-mastoid. 

Symptoms. — The  head  is  rotated  to  the  opposite  side,  the  chin  point- 
ing to  the  unaffected  shoulder,  while  the  ear  approaches  the  shoulder 
of  the  affected  side  (Fig.  585).  If  the  deformity  continues  long  uncor- 
rected, it  may  lead  to  facial  asymmetry,  scoliosis,  or  other  secondary 
deformities  which  cannot  be  remedied. 

Treatment. — The  surgeon  should  first  ascertain  that  the  deformity 
is  not  of  the  symptomatic  variety;  if  it  is,  removal  or  proper  treat- 
ment of  the  cause  of  irritation  usually  will  cause  the  wry-neck  to 
disappear.  If  no  cause  other  than  a  shortening  of  the  muscles  can  be 
found,  attempts  may  be  made  by  massage,  gymnastics,  or  apparatus 
to  overcome  the  deformitv.     If  these  fail,  as  in  most  cases  they  do, 


Fig.  584. — Torticollis  from  cervical  adenitis. 
Children's  Hospital. 


538 


ORTHOPEDIC  SURGERY 


I'k;.    ')bo. — ( 'Diiiit'iiital   tui'tK 
quired  scoliosis.     Note   asymmetry 
Children's  Hospital. 


with    ae- 
of    face. 


the  surgeon  may  resort  to  division  of  the  contracted  structures.     In 
cases  of  short  duration  this  usually  is  quite  efficient,  })ut  in  many 

pntients  the  most  that  can  be 
expected  is  a  lessening  of  de- 
formity. It  is  better  to  divide 
all  resisting  structures  by  open 
section  than  to  attem})t  a  sub- 
cutaneous operation ;  very 
dense  cicatricial  bands,  which 
may  exist  in  the  cervical 
fascia,  should  be  excised,  and 
the  muscles  may  be  divided 
trans\ersely  and  left  unsu- 
tured,  or  some  form  of 
muscle  lengthening,  analogous 
to  the  lengthening  of  ten- 
dons may  be  employed.  The 
head  is  then  dressed  in  an 
over-corrected  position,  main- 
tained by  a  gypsum  case . 
(Fig.  58()),  or  orthopedic  ap- 
paratus. 
Spasmodic  Torticollis,  a  form  of  Tic  Convulsij,  is  an  affection  of 
obscure  origin,  consisting  essentially  in  sudden  tonic  involuntary, 
and  usually  painful  contraction  of  the  neck  muscles,  momentarily 
turning  the  head  into  a  wry- 
neck position.  The  extent  of 
the  spasm,  and  the  number 
of  muscles  involved,  varies 
greatly.  The  disease  usually 
begins  insidiously,  in  young 
adult  life,  but  progresses  with- 
out intermission  until  almost 
the  entire  body  may  be  in- 
volved; any  effort  to  move  or 
speak,  and  especially  any  ex- 
citement, brings  on  a  spasm, 
and  the  patient  may  curl  up 
in  a  knot,  as  it  were,  on  the 
side  affected,  being  abso- 
lutely helpless  and  unable  to 
straighten  himself  out.  ]Many 
surgical  measures  have  been 
tried,  but  none  have  had 
permanent  good  effect;  but 
as  the   same  can   be  said  for 

medical  measures,  the  temporary  relief  which  follows  operation  should 
not  be  despised.     Division  of  the  nerves  supplying  the  cervical  muscles 


Fig.  586. — Gypsum  dressing  after  operation 
for  left-sided  congenital  torticollis.  Age  nine- 
teen years.     Orthopjedic  Hospital. 


DEFORM! TIES  OF  THE  HEM)  AND  NECK 


530 


most  nflVcti'd  is  tlu'  oix^ratioii  usually  (lone,  ('s[)('<ially  dixision  of  the 
spinal  acc('ssor\  or  upper  (rr\ical  nerves  (Keen,  hSUl  j. 

Cervical  Ribs.  On  one  or  both  sides  of  the  neck  a  rudimentary 
ril)  may  he  t'ornied,  usually  attaelied  to  the  seventh  eervieal  vertebra, 
but  occasionally  to  the  sixth.  The  all'ection  is  said  to  be  bilateral  in 
7")  per  cent,  of  eases,  and  occurs  in  females  three  times  as  often  as  in 
males.  If  the  rib  is  very  short,  no  symptoms  may  be  produced,  l)ut 
usuall.\'  it  is  long  enough  to  reach  to  the  subclavian  artery,  which 
passes  o\er  the  rib,  and  may  be  compressed,  causing  .symptoms  of 
munbness,  tingling,  etc.,  in  the  extremity  affected.  Pressure  on  the 
iiraciiial  plexus,  cervical   sympathetic  or  j)ncumogastric   nerves  may 


Fig.  587. — Cervical  rib  (left) ;  age  eighteen  years.    Numbness,  tingling,  etc.,  for 
four  months.     (Dr.  W.  J.  Taylor's  case.)     Orthopaedic  Hospital. 


also  occur.  Usually  no  trouble  is  experienced  until  adult  life  (Fig. 
587).  In  most  cases  the  rib  is  palpable  in  the  neck;  and  the  abnormal 
position  of  the  artery,  as  well  as  changes  in  the  radial  pulse,  may 
simulate  aneurysm.  Rest  for  a  few  weeks,  with  elevation  of  the  arm, 
usually  causes  subsidence  of  acute  symptoms.  When  these  recur, 
and  are  disabling,  excision  of  the  abnormal  rib  should  be  done.  The 
operation  may  be  very  difficult,  from  the  altered  relations  of  blood- 
vessels, ner^•es,  and  muscles,  and  from  the  proximity  of  the  pleura. 
Complete  recovery  is  the  rule,  even  if  temporary  paralysis  occurs 
from  careless  handling  of  the  nerves. 


540  ORTHOPEDIC  SURGERY 

ACQUIRED  DEFORMITIES  OF  THE  UPPER  EXTREMITY. 

Cubitus  Valgus,  or  increase  of  the  normal  ''carrying  angle"  of 
the  upper  extremity,  sometimes  follows  rachitis,  but  most  often  is 
the  result  of  a  fracture  of  the  lower  end  of  the  humerus.  It  is  less 
frequent  and  less  disabling  than  cubitus  varus,  which  almost  always 
is  due  to  fracture,  especially  supracondylar  fractures  of  the  humerus. 
Either  deformity  may  be  treated  by  supracondylar  osteotomy  of  the 
humerus.  Some  surgeons  prefer  to  dress  the  arm  in  full  extension 
after  the  operation:  if  this  is  done,  for  valgus  deformity  the  forearm 
should  be  kept  in  supination,  which  relaxes  the  muscles  passing  from 
the  external  supracondylar  ridge;  while  for  varus  the  forearm  is 
dressed  in  full  pronation,  making  these  muscles  tense,  and,  there- 
fore, restoring  the  carrying  angle.  If  the  elbow  is  dressed  in 
hyperflexion,  as  in  a  recent  supracondylar  fracture,  the  precautions 
mentioned  at  page  340  against  varus  and  valgus  deformities  should 
be  observed. 

Ischemic  Contracture  (Stromeyer,  1S3S;  Volkmann,  18()9)  is  due  to 
muscle  and  nerve  degenerations  following  ischemia  caused  by  pressure 
of  splints  or  bandages  applied  for  a  fracture  of  the  elbow  or  forearm. 
^^ery  rarely  it  has  followed  injury  in  which  no  splint  or  dressing  of 
any  kind  had  been  used.  It  has  been  reported  as  affecting  the  lower 
extremity  also.  Bardenheuer  (1911)  in  his  recent  elaborate  study 
of  the  question,  concluded  that  the  degenerative  changes  were  due  to 
venous  stasis,  the  muscle  cells  being  poisoned  by  metabolic  products 
in  the  blood,  and  that  the  primary  cause  is  not  an  anemia  of  the  parts. 
Nerve  involvement  in  cases  of  ischemic  contracture  has  been  empha- 
sized by  J.  J.  Thomas  (1909).  The  hand  swells  and  becomes  cyanosed, 
and  the  parts  are  extremely  painful;  but  the  constriction  is  not  suffi- 
cient to  cause  gangrene.  After  a  few  days  the  pain  ceases,  and  swelling 
may  subside.  The  damage  is  done  within  a  few  hours,  and  cannot  be 
repaired  merely  by  removal  of  the  splints;  it  is  far  better  to  be  sure 
in  the  first  place  that  the  dressing  used  does  not  interfere  with  the 
circulation.  Usually  the  condition  develops  in  what  appears  an 
insidious  manner  only  because  the  surgeon  is  not  on  the  lookout  for 
it;  if  interference  with  the  circulation  persists  for  several  hours  there 
is  already  nerve  and  muscle  degeneration,  and  if  the  surgeon  was  suf- 
ficiently attentive  he  would  discover  it  at  the  next  dressing,  and  not 
be  surprised  when  subsequent  deformity  develops. 

The  deformity  is  quite  characteristic  (Fig.  588),  resembling  that  of 
ulnar  paralysis;  nor  is  this  resemblance  surprising  since  the  ulnar 
nerve  often  is  involved  (Fig.  589).  But  even  if  the  symptoms  of 
neuritis  are  present,  and  they  are  not  in  all  cases,  there  are  also 
symptoms  of  fibrous  degeneration  of  the  muscles  on  the  flexor  side 
of  the  forearm.  The  joints  are  not  affected,  motion  being  limited 
merely  by  muscular  contracture:  thus,  when  the  wrist  is  fully  flexed, 
extension  of  the  fingers  becomes  possible;  but  efforts  to  straighten 
the  wTist  at  once  cause  flexion  of  the  fingers.    Frequently  there  are 


ACQUIRED  DKFORMlTll'JS  OF  THE   I'l'l'Eli  EXTREMITY     .')  1 1 

prossiire  sores  in  tlio  skin,  and  tlie  resultinji;  cicatrices  aid  in  fixing 
nuiscles,  tendons,  and  niTves,  in  one  almost  inextricable  mass  of 
adhesions. 

Treatment. — \  ery  little  can  be  done  imtil  the  ulcers  have  healed, 
except  to  prevent  further  deformity.  Xo  remedial  treatment  should 
be  undertaken  until  acute  symptoms  ha\e  subsided.  Then  trial  may 
be  made  of  massage  and  passi\e  motion;  but  usually  very  slif^ht  if 
any  improvement  is  secured.     R.  Jones  (1908)  ai)plies  a  malleable 


Fic.  58b. —  I  )cf(ii'iiiit  \-  fiill(iwinj£  \'()lkiiKiiiii's  ischcinic  contraftiirc  and  paralysis 
of  ulnar  nei\e  after  frat-turc  of  elbow.      Orthoi  ledie  Hosijital. 

metal  splint  to  each  finger  up  to  the  carpal  joints,  first  with  the  wrist 
in  full  flexion,  a  position  which  usually  permits  nearly  full  extension 
of  the  fingers;  the  wrist  flexion  is  gradually  diminished  and  the  finger 
extension  progressively  increased  by  changing  the  angle  of  the  finger 
splints;  and  in  the  course  of  several  months  the  contracted  tissues 
may  be  sufficiently  relaxed  to  permit  fair  function.  In  most  cases, 
however,  especially  in  those  complicated  by  nerve  changes,  operation 


Fig.  589. — Ulnar  paralysis  and  Volkmann's  ischemic  contracture  after  fracture 
at  the  elbow.     Episcopal  Hospital. 

is  required.  This  consists  in  a  free  dissection  of  the  muscles,  tendons, 
and  nerves;  in  muscle  and  tendon  lengthening  (Anderson,  1889; 
Littlewood  and  Page,  1898),  and  in  preventing,  so  far  as  possible, 
formation  of  new  adhesions,  by  interposing  flaps  of  fascia  or  pieces 
of  Cargile  membrane^  between  the  various  structures.    Some  brilliant 

1  This  is  thin  gold-beaters'  skin,  made  from  the  peritoneum  of  an  ox,  first  used 
by  an  Arkansas  physician  named  Cargile,  and  introduced  to  professional  notice 
in  1902  by  R.  T.  Morris. 


542  ORTHOPEDIC  SURGERY 

results  have  been  secured  by  these  methods  (Dudgeon,  1902;  G.  G. 
Davis,  190K),  but  in  many  cases  the  operation  has  to  be  rei)eated  a 
number  of  times  Binet  (1910)  has  studied  141  cases  of  Volkmann's 
contracture,  and  prefers  to  treat  them  by  resection  of  the  radius  and 
uhia,  shortening  the  forearm  until  the  tendons  become  relaxed  suffi- 
ciently to  straighten  the  fingers  (Colzi,  1892;  Henle,  1896;  P>oelich, 
1909);  but  while  good  results  have  followed  this  method  it  is  better 
in  every  case  to  make  sure  that  the  nerves  are  freed  from  adhesions. 
Spontaneous  Subluxation  of  the  Wrist  or  Manus  Valga  (Made- 
lung's  Disease,  1878). — The  symptoms  of  this  affection  usually  are 
manifested  about  the  age  of  puberty;  it  affects  particularly  females; 
involves  both  wrists  in  about  50  per  cent,  of  cases;  is  characterized 
by  dorsal  projection  of  the  lower  ends  of  the  ulnse,  by  slight  radial 
deviation  of  the  hand,  and  in  its  more  advanced  stages  by  subluxa- 
tion of  the  wrist  forward  at  the  radiocarpal  joint  (Fig.  590).  Espe- 
cially characteristic  in  radiograms  is  the  widening  of  the  interosseous 
space,  due  to  incur^'ation  of  the  lower  end  of  the  radius,  the  normal 
flexor  concavity  of  which  becomes  much  exaggerated.  The  hand  thus 
is  carried  forward  with  the  articular  surface  of  the  radius,  while  the 
ulna,  which  is  not  displaced  forward,  appears  to  be  unduly  prominent. 
Siegrist  (1908)  collected  62  cases,  only  10  of  which  were  in  males. 


Fig.  590. — Madeluiig'.s  disease;  male,  aged  twenty-four  years.     Began  about 
eight  years  of  age.     Episcopal  Hospital. 

The  aft'ection  has  been  attributed  by  some  to  adolescent  rachitis; 
others  are  s'atisfied  to  describe  it  as  an  obscure  form  of  osteitis  affecting 
the  radius.  In  the  Tast  few  years  there  has  been  a  tendency  to  regard 
it  as  a  congenital  deformity,  to  which  attention  is  first  directed  at 
an  age  when  local  over-exertion  and  constitutional  malnutrition  exert 
their  influence.  In  addition  to  the  deformity  there  often  is  discom- 
fort from  pain  or  ache,  and  some  disability  from  loss  of  extension  and 
circumduction  at  the  wrist.  Usually  these  are  relieved  In'  si)linting, 
or  orthopedic  apparatus,  with  constitutional  treatment.  In  severe 
cases  osteotomy  of  the  radius  may  be  done  to  overcome  deformity. 

Contraction  of  the  Palmar  Fascia  (Dupuytren's  Contraction,  1832). 
— This  afl'ection  occurs  in  adults  past  middle  life,  jjarticularly  men, 
and  in  some  cases  seems  to  be  caused  by  slight  recurring  trauma  from 
the  handles  of  tools,  canes,  etc.  The  patients  often  are  gouty.  In 
about  half  the  cases  both  hands  are  aft'ected,  usually  the  right  before 


ACQl'llil-^T)   nKFOlUUTIE^  OF  THE  LOWER  EXTREMITY     :yV.\ 

tlie  left.  TIio  fascia  is  the  seat  of  clironic  infiaminatory  cluui^es,' 
with  seeoudary  contraction;  it  l)ec()mes  densely  adherent  to  the  skin; 
and  the  resnltinj:;  deformity  may  totally  disable  the  patient.  The 
tlmnil)  and  index  fin|,a'r  are  the  last  to  succnmh. 


Fig.  591. — Dupuytrcn's  contracture  of  the  palmar  fascia;  earlj-  stage.     Age 
•  sixty-six  years.     Episcopal  Hospital. 

Temporary  relief  may  be  secured  by  tenotomy  of  the  tense  fascial 
bands,  introducing  the  tenotome  between  the  skin  and  fascia  and  cut- 
ting downward  (Adams,  1879) ;  the  fingers  should  be  dressed  on  a  splint 
in  full  extension  for  three  weeks,  and  this  splint  should  be  worn  at 
night  for  three  weeks  longer.  But  recurrence  of  the  deformity  is  usual. 
Excision  of  the  contracted  bands  was  introduced  by  Kocher  (1SS7), 
and  Keen  (1906)  reflected  a  skin  flap,  including  the  adherent  fascia, 
which  was  then  dissected  off  the  skin  before  this  was  replaced.  The 
fascia  is  so  densely  adherent  that  some  sloughing  is  liable  to  occur. 
Lexer  and  others  have  excised  skin  and  fascia  in  one  piece,  and  filled 
the  gap  by  a  flap  of  skin  transplanted  from  elsewhere. 

Trigger  Finger. — Trigger  finger  is  a  condition  in  which  there  is  some 
obstacle  to  vohmtary  flexion  or  extension  of  the  finger,  which  flies 
"shut"  or  "open"  when  passively  moved  past  the  position  where 
it  catches.  The  usual  obstacle  is  a  fusiform  thickening  of  one  of  the 
flexor  tendons,  and  the  hitch  occurs  where  the  deep  tendon  perforates 
the  superficial.  If  rest  on  a  splint  for  some  weeks,  followed  by  massage, 
proves  inefTectual  in  relieving  the  condition,  the  tendon  sheath  may 
be  opened  and  the  thickening  of  the  tendon  excised.  Cotton  (1911) 
refers  to  160  cases,  in  about  40  of  which  operation  was  done. 

ACQUIRED  DEFORMITIES  OF  THE  LOWER  EXTREMITY. 

Coxa  Vara. — Normally  the  neck  of  the  femur  forms  an  angle  of 
about  135  degrees  with  the  shaft;  when  this  angle  is  notably  decreased 

1  These  are  classed  by  the  Lyons  surgeons  as  a  form  of  inflammatory  tubercu- 
losis. 


544 


onrnoPEDic  surgery 


(115  degrees  or  less)  coxa  vara  is  said  to  exist.  The  deformity  con- 
sists in  elevation  of  the  great  trochanter  and  a  relative  depression 
of  the  femoral  head,  which,  however,  retains  its  position  within  the 


Fig.  51)2. — Coxa  vara,  the  result  of  injury  during  infauc.w 
Episcopal  Hospital. 


re  SIX  years. 


Fig.  593.— Skiagraph  of  double  coxa  vara  (rachitic).     Note  rachitic  pelvis- 
acetabula  pressed  together.     Orthopi3edic  Hospital. 


ACQUlUEl)  DEI'OHMITIES  OF  THE  LOW  Eli  EXTREMITY     54o 

uectabiilimi.  (^oxa  \  aru  may  result  from  trauma,  especially  ej)i[)liyseal 
separation  of  tiie  head  or  fracture  of  the  (;ervix  in  children  (Fig.  ;')92); 
from  rachitic  softening  of  tlie  bones,  when  the  deformity  usually 
is  bilateral  (Fig.  r)9.S) ;  or  from  no  well  very  defined  causes,  chiefly  in 
a(h)Iescents.     (See  Rottenstein  and  Ilou/.el,"  1<)I();  Calve,  lOlO.) 

Symptoms.  Tiie  symi)tonis  are  those  of  the  underlying  or  preceding 
condition;  slight  limp,  limitation  of  abduction,  because  the  trochanter 
strikes  the  pelvis;  marked  prominence  of  the  trochanter  when  the 
thigh  is  flexed  (Fig.  594);  increased  range  of  adduction,  especially 
when  the  thigh  is  flexed;  elevation  of  the  trochanter  above  Nelaton's 


595. — Whitman's    vvcclfio-shiiped    oste- 
otoniv  i)f  tlic  femur  for  coxa  vara. 


Fig.  594. — Coxa  vara  from  fracture 
of  cervix  fenioris  as  infant.  Note 
prominence  of  great  trochanter  when 
thigh  is  flexed.     Episcopal  Hospital. 


Fit;.  596. — Whitman's  operation  for  coxa 
vara.  Consolidation  has  occurred  in  the 
abducted  position. 


line;  and,  in  cases  due  to  trauma,  usually  external  rotation  of  the 
lower  extremity.  There  is  moderate  shortening,  but  seldom  much 
pain,  relief  being  sought  for  the  limp  and  deformity. 

Treatment. — In  many  cases  no  treatment  is  required;  in  some,  the 
addition  of  a  lift  to  the  heel  brings  relief  by  overcoming  shortening. 
In  cases  with  great  deformity  a  cuneiform  osteotomy  of  the  femur 
may  be  done,  as  advised  by  Whitman  (1901),  removing  a  w^edge 
with  its  apex  at  the  lesser  trochanter;  or  simple  linear  osteotomy 
may  suffice.  The  thigh  is  dressed  in  extreme  abduction,  and  when 
consolidation  is  complete,  adduction  will  restore  approximately  the 
normal  relations  of  neck  and  shaft  (Figs.  595  and  590).  In  recent  cases 
of  impacted  fracture  of  the  head  or  neck  in  children  or  adolescents, 
35 


546 


ORTHOPEDIC  SURGERY 


the   deformity   may   be   overeome   by   forcible   abduction    under   an 
anesthetic. 

Coxa  Valga  (Fig.  597)  is  a  much  rarer  conditi(jn,  in  which  the  neck 
of  the  femur  makes  with  the  shaft  an  angle  of  more  than  135  degrees. 
The  trochanter  is  less  i)rominent  than  normally,  abduction  is  increased 
and  adduction  diminished.  There  usually  is  outward  rotation  of 
the  lower  extremity.  The  deformity  may  be  congenital  and  usually 
is  observed  in  limbs  which  never  have  borne  any  weight.  P^fforts 
may  be  made  to  increase  the  adduction  by  manipulation  under  an 
anesthetic. 


Fig.  597. — Coxa  valga,  apparently  congenital,  in  a  girl  of  twelv'e  years.  Angle 
between  neck  and  shaft  is  165  degrees  on  the  right;  on  the  left  (normal)  it  is  130 
degrees.     Episcopal   Hospital. 

Snapping  Hip  (die  schnellende  Hiifteja  Ilanchea  Ressort).  This  affec- 
tion has  been  the  subject  recently  of  an  elaborate  study  by  L.  Heully 
(1911),  who  has  collected  57  cases.  He  proposes  the  term  "  ressaut 
fascio-ghiteal ,"  as  explaining  what  he  believes  to  be  the  pathology  of 
the  condition  which  has  been  recognized  since  1859,  though  dispute 
as  to  its  nature  has  always  existed.  Perrin,  who  reported  the  first 
case,  believed  it  to  be  a  form  of  voluntary  luxat  on  of  the  hip; 
but   the  study   of   Heully  confirms   the   opinion  of   Morel-Lavallee, 


ACQUIRED  DEI'VRMITIKS  OF   THE  LOWER  EXTREMITY     547 

Clmssaijjiiao,  and  others,  that  it  is  duo  to  sudden  slippinj^  of  the  fascia 
hita  (altered  by  injury  or  ('on<cenitally  deformed)  oxer  tlie  surface 
of  tlie  fi;reat  troclianter.  The  j)lienonienon  occurs  esj)ecially  (hirinji; 
Hexion  and  internal  rotation  of  the  thi^h,  but  in  some  cases  slij^ht 
movements  of  the  pelvis  on  the  lower  extremity  are  sufficient  to 
])roduce  it.  In  traumatic  cases  the  lesion  is  sey)aration  of  the  up])er 
l)art  of  the  tendon  of  the  gluteus  maximus  from  its  insertion  in  the 
linea  aspera,  and  the  snap  occurs  involuntarily  and  is  painful;  while 
in  conp;enital  cases  it  is  not  painful  and  usually  is  under  voluntary 
control,  possibly  being  due  to  abnormally  low  insertion  of  the  gluteus 
tendon  in  the  linea  aspera  (Ileully).  The  defect  may  be  repaired 
by  suturing  the  tendon  to  the  periosteum  of  the  great  trochanter 
and  a])()neur()sis  of  the  vastus  externus. 

Anterior  Metatarsalgia. — T.  G.  Morton  in  1876  described  a  condition 
which  was  b^'lie^■e(l  by  him  to  be  due  to  pinching  of  a  nerve  between 
the  heads  of  the  fourth  and  fifth  metatarsal  bones  ("^Morton's  toe"). 
A  sudden  unendurable  cramp  in  the  anterior  metatarsus  occurs  while 
the  patient  is  walking,  and  he  is  forced  to  remove  the  shoe  at  once, 
rub  and  manipulate  the  foot,  and  flex  and  extend  the  toes,  until  the 
l)ain  passes.  This  series  of  events  may  be  repeated  a  number  of 
times,  but  except  in  the  most  aggravated  cases  the  attacks  never 
come  on  except  when  walking,  and  with  a  shoe  on  the  foot.  More 
recent  observations,  especially  by  Goldthwait  and  Whitman,  have 
shown  that  weakness  in  the  transverse  arch  of  the  foot  is  an  important 
factor,  and  may  cause  various  minor  symptoms  before  metatarsalgia 
develops.  Callosities  may  form  on  the  sole  over  the  heads  of  the 
metatarsals,  especially  the  second  and  third;  and  pain  may  be  caused 
by  lateral  compression  by  a  shoe  which  would  be  comfortable  if  the 
normal  convexity  of  the  arch  was  maintained.  Relief  usually  may 
be  obtained  by  wearing  broader  shoes,  or  b.y  applying  a  small  longi- 
tudinal pad  beneath  the  sole  to  support  the  centre  of  the  transverse 
arch,  or  a  support  may  be  worn  in  the  shoe  (beneath  the  insole)  just 
back  of  the  heads  of  the  metatarsals,  thus  relieving  them  from  strain; 
such  an  application  is  known  as  an  anterior  heel.  The  patient  should 
actively  exercise  the  toes  in  flexion,  and  may  benefit  from  massage. 
IVIorton  excised  the  head  and  neck  of  the  aft'ected  metatarsal. 

Flat-foot  (Pes  Planvs). — This  very  frequent  aftection  is  an  evidence 
of  weakness  in  the  foot.  In  a  foot  that  is  merely  weak,  however, 
the  antero-posterior  arch  may  still  be  preserved,  but  a  tendency 
to  pronation  exists:  when  weight  is  put  on  the  foot  the  internal 
malleolus  descends  and  rotates  backward,  causing  a  relative  outward 
displacement  of  the  anterior  part  of  the  foot;  the  patient  walks  with 
the  toes  well  turned  out,  and  to  bring  the  two  feet  parallel  it  may  be 
necessary  to  rotate  both  entire  lower  extremities  inward,  so  that  the 
patellae  look  toward  each  other  rather  than  anteriorly.  In  truly  flat 
feet  the  arch  is  depressed,  and  in  aggravated  cases  the  scaphoid  may 
rest  on  the  floor  (Fig.  598).  The  affection  is  common  at  all  ages,  and 
may  be  very  disabling.     In  adolescents  painful  flat-foot  often  is  an 


548 


ORTHOPEDIC  SURGERY 


early  evidence  of  tuberculosis  of  the  tarsus,  and  this  diagnosis  always 
should  be  carefully  considered.  In  young  children  the  foot  remains 
perfectly  flexible,  but  if  the  condition  persists  for  years  unrelieved, 
great  rigidity  may  develop;  and  in  adults  more  or  less  rigidity  is  the 
rule.  In  cases  where  rigidity  is  absent  much  may  be  done  by  proper 
exercises,  even  without  mechanical  support.  The  patient  should 
rise  on  to  the  toes  of  both  feet  simultaneously,  from  ten  to  twenty 
times,  morning  and  night;  he  should  then  attempt  to  supinate  his 
feet  the  same  number  of  times  by  flexing  his  toes  and  contracting 
the  tibialis  anticus  and  posticus  muscles;  and  flexion  exercises  of  the 
toes  with  the  feet  oft'  the  ground  also  should  be  prescribed.  Walking 
on  the  toes,  and  on  the  outer  side  of  the  soles  is  another  valuable 
exercise.  In  most  cases,  however,  it  is  desirable  to  support  the  arch 
in  walking:  for  this  purpose  the  first  thing  is  to  secure  a  pair  of  strong 


Fig.  598.— Flat  feet, 
years.  (See  Fig.  599.) 
pital. 


a    a    boy  of    eight 
Orthopsedic  Hos- 


FiG.  599. — Flat  feet  foot-prints. 
Same  patient  as  Fig.  598.  Ortho- 
pasdic  Hospital. 


shoes,  made  on  a  straight  or  nearly  straight  last,  with  broad  toes, 
low  heels  and  a  wide  shank;  the  shoes  should  be  "high"  shoes,  laced. 
Many  sole  plates  are  sold  in  the  stores  for  the  purpose,  but  as  they 
scarcely  ever  fit  the  foot  to  which  they  are  applied,  it  rarely  is  proper 
to  use  them.  If  a  sole  plate  is  to  be  used  it  should  be  made  for  the 
individual  patient,  moulded  on  a  cast  of  this  foot  taken  in  the  resting 
position.  An  easier  and  as  efficient  method,  I  believe,  is  to  have  a 
shoemaker  insert  a  steel  strip  in  the  shank  of  the  shoe,  and  then  to 
build  up  the  arch,  to  any  height  desired,  by  properly  cut  felt  pads 
placed  beneath  the  inner  sole.  The  height  of  this  pad  may  be  increased 
or  decreased  at  will.  In  very  rigid  feet,  benefit  is  derived  from  massage, 
passive  movements,  and  baking.  Sometimes  "  Mobilisierung"  under 
an  anesthetic,  with  tenotomy  of  the  tendon  of  Achilles  or  of  the  pero- 
neal tendons,  may  be  necessary;    after  such  an  operation  the  foot 


ACQUIRED  DEFORMITIES  OF  THE  LOWER  EXTREMITY     549 

is  dressed  in  plaster  of  Paris  in  the  varus  i^osition  for  several  weeks, 
when  proper  ai)paratns  may  he  appHech 

Hammer  Toe.  Hanuner  toe  (Digitus  iikiIIcn.s)  is  a  dcforniity  of 
extension  at  the  nietatarso-piiahingeal  joint  and  flexion  at  tiie 
proximal  interphalangeal  joint  (Fig.  600).  It  is  commonest  in  the 
second  toe,  which,  being  the  longest,  suffers  most  from  short  and 
narrow  shoes.  The  condition  usually  })egins  in  childhood.  A  corn 
forms  over  the  prominent  i)halangeal  joint,  and  the  end  of  the  toe 
liecomes  club-shaped.  If  massage,  application  of  adhesive  i)laster 
strapping,  etc.,  do  not  relieve  symptoms,  tenotomy  of  tlie  contracted 
tendons  (extensor  and  flexor)  may  be  done;  and  in  relapsed  cases,  the 
toe  may  be  anii)utate(l. 


Fig.  600. — Hammer  toe  in  a  man  of  Fig.  601. — Hallux  valgus,    with    a   bunion 

twenty-six;  duration  since  childhood.       over  the  head  of  the    first    metatarsal    bone. 
Episcopal  Hospital.  Age  sixty-nine  years.     Orthopaedic  Hospital. 

Hallux  Valgus. — Hallux  valgus  is  a  deformity  in  which  the  great 
toe  is  abducted,  often  lying  on  the  top  of  the  other  toes.  This  results 
in  marked  prominence  of  the  first  metatarso-phalangeal  joint;  and 
over  this  a  bursa  is  formed  by  friction  of  the  shoe  (Fig.  601).  In  some 
cases,  the  primary  cause  of  the  deformity  is  adduction  of  the  first 
metatarsal  bone,  due  to  the  presence  of  a  congenital  anomaly,  a  bone 
known  as  the  intermetatarseum  (J.  K.  Young,  1910);  but  I  have 
seen  the  intermetatarseum  present  without  hallux  valgus,  and  in 
most  cases  no  such  bone  exists,  the  deformity  being  caused  by  ill- 
fitting  shoes.  If  proper  shoes,  which  do  not  abduct  the  toes,  do  not 
secure  relief,  excision  of  the  projecting  head  of  the  first  metatarsal 
may  be  done,  C.  H.  Mayo  (1908)  preserves  the  bursa  and  inserts 
it  between  the  bones. 

Painful  Heel. — Painful  heel  may  be  due  to  a  variety  of  causes. 
Trauma  may  cause  rupture  of  some  fibres  of  the  tendo  Achillis,  or 
produce  inflammation  in  the  retrocalcaneal  bursa   (Achillobursitis), 


550 


ORTHOPEDIC  SURGERY 


or  in  a  bursa  sometimes  present  between  the  Achilles  tendon  and 
the  skin;  or  it  may  cause  strain  on  the  attachment  of  the  plantar 
fascia,  as  is  common  in  flat  feet.  Subsequently,  exostoses  may  develop 
at  these  points  of  strain.  Infection^-,  especially  gonococcic,  and 
some  forms  of  sub-pyemic  or  cryptogenous  infection  (Fig.  G02)  may 
cause  exostoses  to  form  on  the  calcaneum  or  other  tarsal  bones;  or 
similar  changes  may  be  an  evidence  of  hyperfrophic  arthritis  (p.  456). 


Fig.  602. — Exostoses  of  calcaneum  at  attachments  of  plantar  fascia  and  tendo  Achillis, 
in  a  patient  aged  forty-four  years.  Duration  of  s>-mptoms,  over  two  months.  Also 
has  incipient  hypertrophic  arthritis  of  hip.  Orthopaedic  Hospital. 


Treatment. — The  treatment  consists  in  care  of  the  underlying 
condition  (sprain,  flat-foot,  gonorrhea,  etc.);  local  rest  by  proper 
orthopedic  shoes,  etc.;  and,  in  cases  which  resist  conservative 
measures,  in  excision  of  the  exostoses. 


niAPTKR    XVII. 
SnUiKKV  OF  THE  IIKAD. 


SURGICAL  AFFECTIONS  OF  THE  SCALP. 

Birth  Injuries. — Durinij;  parturition  that  portion  of  the  scalp 
whic'li  protrudes  into  the  birth  canal  may  become  edematous  from 
pressure  on  surrounding  parts;  this  condition,  which  is  known  as 
caput  smrcdaneum,  may  be  recognized  by  the  history  of  prolonged 
or  difficult  lal)or,  by  tlie  facts  that  it  is  present  at  birth,  that  the 
att'ectetl  area  pits  on  pressure  and  presents  no  signs  of  inflammation; 
while  it  may  be  distinguished  from  cephalhematoma  (see  below)  by 
the  fact  that  the  swelling  is  not  limited  to  the  outline  of  one  bone. 
The  swelling  disappears  in  a  few  hours  or  days,  and  usually  no  treat- 
ment is  necessary.  Cephalhe- 
matoma is  an  extravasation  of 
blood  beneath  the  pericra- 
nium; it  is  encountered  in 
about  one  labor  out  of  two 
hundred.  Usually  the  right 
parietal  is  the  bone  affected, 
and  it  is  probable  that  in 
many  cases  the  bone  itself  is 
directly  injured,  either  bent 
or  broken  (p.  564).  As  the 
pericranium  is  attached  at 
the  sutures,  the  hemorrhage 
never  passes  the  limits  of  the 
bone  affected;  generally  the 
condition  is  not  noticed  for  a 
day  or  two  after  birth,  and 
at  this  time  the  blood  at  the 
periphery  may  have  become 

clotted  or  organized,  so  that  the  scalp  presents  an  indurated  ring  with 
a  softened  or  fluctuating  centre.  Occasionally  thin  plates  of  sub- 
periosteal bone  develop,  and  the  bone  crackles  on  palpation.  In 
most  cases  no  treatment  is  required,  but  if  no  evidence  of  absorption 
is  seen  after  two  weeks  the  fluid  may  be  evacuated  by  puncture; 
pressure  should  then  be  applied  to  prevent  re-accumulation.  Should 
infection  of  the  hematoma  occur,  from  the  deep  skin  cocci  or  through 
the  blood  stream,  it  should  be  drained  (Fig.  603). 

Contusions. — Contusions  of  the  scalp  are  frequent  at  all  ages.  If 
the  head  is  examined  immediately  after  the  injury  the  impress  of  the 
vulnerating  body  may  be  detected;  but  swelling  occurs  very  quickly, 


Fig.  603. — -Suppurating  cephalhematonia  in 
an  infant  of  five  weeks.  Incised.  Death  in 
four  days.     Children's  Hospital. 


552 


SURGERY  OF   THE  HEAD 


and  usually  the  only  signs  are  those  of  edema,  and  possibly  hematoma. 
The  blood  usually  is  extravasated  in  the  subcutaneous  tissues,  super- 
ficial to  the  aponeurosis  of  the  occipito-frontalis.  It  may  be  difficult 
to  distinguish  such  cases,  after  the  lapse  of  a  few  hours,  from  depressed 
fractures  of  the  skull  as  the  contusion  presents  a  soft  depressed  centre, 
surrounded  by  an  indurated  area  due  to  inflammatory  reaction  and 
commencing  organization;  but  firm  pressure  in  the  centre  detects 
solid  bone  at  the  same  level  as  the  surrounding  cranial  surfaces,  and 
there  is  no  irregular  outline  to  the  depressed  area,  such  as  is  commonly 
present  in  fracture;  moreover,  the  elevated  margin  moves  \\ith  the 

scalp  upon  the  bone  beneath.  In  cases 
of  doubt  the  scalp  should  be  incised  and 
the  skull  inspected.  A  hematoma  beneath 
the  occipito-frontalis  is  widely  diffused, 
and  may  be  of  great  size.  In  most  cases 
hematomas  of  the  scalp  subside  under 
pressure  by  bandages,  application  of  cold, 
and  rest  in  bed;  if  no  diminution  in  size 
is  evident  after  ten  days,  or  if  infection 
occurs,  the  hematoma  should  be  incised, 
and  pressure  applied,  when  the  cavity  will 
heal  by  granulation. 

Wounds. — Wounds  of  the  scalp  may 
result  from  blunt  force,  as  well  as  from 
cutting  instruments,  as  the  scalp  is  very 
readily  split  on  the  underlying  bone. 
Bleeding  is  free,  as  the  bloodvessels  are 
unable  to  contract  and  retract,  being 
enmeshed  in  the  firm  fibrous  processes 
which  bind  the  skin  to  the  aponeurosis. 
This  also  renders  it  difficult  to  catch  the 
bleeding  points  in  hemostats,  or  to  apply 
ligatures;  and  the  surgeon  often  must  de- 
pend on  sutures  to  arrest  the  bleeding. 
Temporary  control  of  hemorrhage  is  easily 
secured  by  pressure  on  the  margins  of  the  wound ;  and  during  an  oper- 
ation hemostasis  sometimes  may  be  secured  by  applying  an  Esmarch 
band  or  other  form  of  elastic  tourniquet  around  the  crown  of  the 
head.  Wounds  w^hich  divide  the  occipito-frontalis  aponeurosis  trans- 
versely gape  much  more  than  longitudinal  wounds;  and  when  the 
loose  subaponeurotic  areolar  tissue  is  opened  there  is  much  greater 
danger  of  infection  arising,  especially  if  the  wound  is  closed  without 
drainage  (Fig.  604).  Owing  to  the  great  vascularity  of  the  parts 
large  portions  of  the  scalp  may  be  avulsed  and  yet  retain  their  vitality 
when  properly  cleansed  and  sutured  in  place.  When  the  skull  has 
been  denuded  of  its  pericranium  over  large  areas,  some  caries  is 
ver}'  apt  to  occur,  but  if  the  soft  parts  are  promptly  replaced  no 
such  result  need  be  anticipated  unless  infection  is  present. 


Fig.  604. — Lacerated  wound  of 
the  scalp,  with  subaponeurotic 
cellulitis;  the  result  of  sealing 
the  wound  with  a  cotton  and 
collodion  dressing.  Forty-eight 
hours  after  injury  the  cellular 
infiltrate  had  gravitated  into  the 
temporal  region  where  it  was 
arrested  by  the  attachment  of 
the  temporal  fascia  to  the  zj-- 
goma.     Episcopal  Hospital. 


SURGICAL  AFFECTIONS  OF  THE  SKULL 


553 


In  all  scalp  wounds  a  lar«;(*  surroundiiijj;  area  should  he  shaved, 
all  t'()rei>,ni  hodies  reuio\ed  from  the  wound,  and  this  should  he  cleaned 
with  antiseptics.  Silkworm  ^\\t  sutures 
should  he  used,  and  if  there  is  any  risk  of 
a  hematoma  forming,  or  if  the  subapon- 
eurotic sj)ace  has  been  opened,  the  wound 
sliould  be  ilrained  for  a  few  days. 

Tumors.  —  Tumors  of  the  scalp  apart 
from  sebaceous  cysts{  Fig.  223,  p.  2()5)  are 
not  very  frequent.  In  infancy  dermoid 
ci/sts  (Fig.  22(),  p.  2()())  sometimes  are 
seen;  these  usually  grow  in  the  region  of 
the  embryonal  clefts,  occurring  in  or  near 
the  orbit,  at  the  glabella,  or  over  one  of 
the  fontanelles;  usually  they  are  more  or 
less  immobile,  deep-seated,  and  are  not 
attached  to  the  epiderm,  being  thus  easily 
distinguished  from  ordinary  wens.  If  not 
removed  in  infancy,  the  underlying  bone 
may  be  absorbed  from  pressure,  and  the  growth  may  become  adherent 
to  the  dura  mater,  making  its  removal  more  difficult.  Papillomatous 
growths  of  the  scalp  should  be  eradicated  by  cauterization,  or  excised, 
as  they  are  prone  to  undergo  epitheliomatous  change.  Epithelioma 
often  develops  in  scars  from  burns,  syphilitic  ulcers,  etc.  Sarcoma 
may  arise  in  the  scalp  or  the  cranial  bones,  and  the  latter  are  rapidly 
invaded  by  tumors  which  at  first  were  superficial  (Fig.  fiOo) .  Usually 
no  operation  is  of  any  use. 


¥ir..  tjUo. — Sarcoma  of  scalp. 
Death  a  few  months  after 
photograph  was  made.  (Dr. 
W.  L.  Rodman's  case.)  Pres- 
byterian Hospital. 


SURGICAL  AFFECTIONS  OF  THE  SKULL 

Congenital  Malformations. — Cephalocele. — Occasionally  at  or  soon 
after  birth  a  fluctuating  tumor  of  the  head  is  found  wdiich 
evidently  protrudes  through  the  skull  and  is  composed  of  cranial 
contents.  The  growth  occurs  oftenest  in  the  region  of  the  posterior 
fontanelle  (occipital  cephalocele),  though  it  ma}'  also  protrude  at  the 
root  of  the  nose  (sincipital  cephalocele),  or  very  rarely  at  the  anterior 
fontanelle  or  through  one  of  the  cranial  sutures.  The  tumor  usually 
is  wholly  or  partly  reducible  by  pressure,  which  if  excessive  may 
cause  symptoms  of  cerebral  compression  (p.  573) ;  and  it  becomes  more 
prominent  and  tense  when  the  child  cries.  It  frequently  is  possible 
to  detect  the  defect  in  the  cranium  through  which  the  protrusion 
occurs.  If  the  protrusion  is  composed  solely  of  the  meninges,  with 
subarachnoid  fluid,  it  is  called  a  meningocele;  an  encephalocele  contains 
also  some  brain  substance;  while  a  protrusion  formed  by  a  diver- 
ticulum of  one  of  the  ventricles  is  called  a  hydrencephalocele  or  an 
encephalocystocele.  It  formerly  was  believed  that  the  most  frequent 
form  was  the  meningocele;  but,  though  the  protrusion  resembles 
this  macroscopically,  histological  study  has  proved  that  most  cases 


554  SURGERY  OF   THE  HEAD 

really  are  encephalocystoceles,  as  the  cavity  of  the  cyst  is  lined  by 
ependymal  cells,  which  are  directly  continuous  with  those  of  the 
ventricles  of  the  brain,  while  the  cyst  walls  are  formed  by  an 
attenuated  layer  of  cerebral  tissue. 

The  diagnosis  usually  is  not  difficult,  though  deep  lying  dermoids, 
in  contact  with  the  dura  mater,  and  having  its  motions  transmitted 
to  them,  sometimes  are  mistaken  for  cephaloceles.  The  prognosis  is 
poor,  most  infants  either  dying  soon  after  birth,  or  presenting  in 
later  life  evidences  of  cerebral  defects  (porencei)hal()n,  liydrocephalus, 
idiocy,  etc.).    Spina  bifida  often  coexists. 

Treatment. — Protection  should  be  afforded  the  tumor,  to  prevent 
excoriation  and  infection.  In  most  cases  little  else  can  be  done; 
but  if  there  is  only  a  small  channel  of  communication  with  the  cranial 
cavity,  and  if  the  child's  mentality  appears  normal,  removal  of  the 
tumor  may  be  attempted,  with  closure  of  the  skull  defect  by  trans- 
planting a  bone  flap  from  a  neighboring  portion  of  the  skull. 

Microcephalus. — When  the  skull  is  abnormally  small,  the  child 
often  is  idiotic  or  feeble-minded.  Keen  (1890),  Lannelongue  (1891) 
and  others  have  done  linear  craniotomy  for  this  condition,  on  the 
theory  that  premature  ossification  of  the  cranial  sutures  caused 
compression  of  the  brain,  and  that  division  of  the  cranium  in  a  line 
parallel  with  the  sagittal  suture  would  allow  the  brain  to  expand. 
But  the  modern  belief  is  that  the  smallness  of  the  skull  is  the  result 
of  lack  of  cerebral  development,  and  is  not  the  cause  of  it.  Agnew 
said  the  operation  was  no  more  use  than  cutting  a  piece  out  of  a 
turtle's  shell,  to  make  him  grow  larger;  and  this  is  the  general  belief 
of  surgeons  of  today.    There  is  no  surgical  treatment  for  idiocy. 

Hydrocephalus. — This  is  a  symptom  of  some  disease  of  the  brain 
or  its  mem})ranes,  interfering  with  the  normal  circulation  of  the 
cerebrospinal  fluid,  and  causing  it  to  collect  in  abnormal  amounts 
on  the  surface  of  the  brain  or  within  its  ventricles.  Hydrocephalus 
thus  is  classified  as  external  and  internal;  and  it  may  be  acute  or 
clironic,  congenital  or  acquired. 

External  Hydrocephalus,  in  which  the  fluid  collects  in  the  sub- 
arachnoid space,  is  very  rare;  many  cases  designated  by  this  name 
really  are  properly  classed  as  other  conditions.  There  may  be  acute 
edema  of  the  subarachnoid  tissues,  as  the  result  of  trauma;  the 
"acute  serous  meningitis"  of  Quincke  (1893)  belongs  here,  as  also 
does  "hydrops  ex  vacuo,"  in  which  fluid  collects  and  fills  the  space 
left  by  skrmkage  of  the  brain  from  injury  or  disease. 

Internal  Hydrocephahis. — This  is  met  with  in  two  distinct  forms, 
the  congenital  and  the  acquired. 

Acquired  Hydrocephalus  usually  results  from  obstruction  or  actual 
occlusion  of  the  foramina  at  the  base  of  the  brain,  by  which  the 
cerebrospinal  fluid  leaves  the  ventricles;  and  the  most  frequent 
cause  is  a  basal  meningitis,  generally  tuberculous  (p.  579).  Each 
lateral  ventricle  communicates  with  the  third  ventricle  tlirough  a 
foramen  of  IMonro;  while  in  the  roof  of  the  fourth  ventricle  (which 


// }  ■  DROCEPHA  L  US  555 

(IniiiLs  the  third  ventricle  through  the  aqueduct  of  Sylvius)  are  found 
the  foramina  of  Key  and  Retzuis,  and  that  of  IVIagendie,  which  are 
the  channels  of  coinnuniication  between  the  ventricular  ca\ities 
and  the  suharachnold  space  of  the  brain,  this  being  contiinious  with 
the  subarachnoid  space  of  the  chord.  Occlusion  of  one  foramen  of 
Monro  may  cause  unilateral  hydrocephalus.  Though  most  cases 
of  acquired  internal  hydrocephalus  are  due  to  basal  meningitis,  yet 
ejMMidynial  inflammations,  or  pressure  of  a  brain  tumor  causing 
obstruction  of  the  \eins  of  (ialen  sometimes  are  resj)onsil)le  for  the 
condition  by  })roducing  edema  from  venous  stasis.  The  syinptoms 
of  the  acquired  form  of  internal  hydrocephalus  are  those  of  the  causa- 
tive condition  complicated  by  cerebral  compression  (p.  573);  and 
the  treatment  consists  in  relieving  the  compression,  as  removal  of  the 
cause  of  the  obstruction  usually  is  out  of  the  question.  Lumbar 
puncture  (p.  157)  is  useless,  as  the  occlusion  of  the  basal  foramina 
prevents  evacuation  of  the  ventricles  by  this  route;  and  such  treat- 
ment may  prove  quickly  fatal  by  withdrawing  the  support  of  the 
cerebrospinal  fluid  from  beneath  the  medulla,  and  allowing  the  sui)er- 
incumbent  pressure  to  crowd  this  down  into  the  foramen  magnum 
(p.  574).  But  as  a  palliative 
measure  repeated  tapping  of  the 
lateral  ventricles  may  be  done 
(v.  Bergmann,  1888)  through 
a  trephine  opening  at  Keen's 
point  (1888):  this  is  3  cm.  be- 
hind and  an  equal  distance  above 
the  external  auditory  meatus; 
the  needle  is  entered  through 
the  posterior  part  of  the  first 
temporal    convolution,    and     is    '  .—  - 

directed    toward    the    summit  of  Fig.  606.— Shaded  portion  on  surface  of 

,1  •,         •  ,1  ,    •   1         the   brain   indicating   the    position  of   the 

the  opposite  pmna;  the  ventricle      lateral  ventricle  within.     (Campbell.) 

should  be  reached  at  a  depth  of 

about  4  cm.  Kocher's  point  (1894),  is  2.5  cm.  to  3  cm.  from  the  median 
line  and  3  cm.  anterior  to  the  precentral  fissure  (see  Cranio-cerebral 
Topography,  p.  567) ;  the  needle  is  directed  downward  and  backward 
and  enters  the  ventricle  at  a  depth  of  4  or  5  cm.  Fig.  606  illustrates 
the  relative  position  of  the  lateral  ventricles  to  the  surface  of  the  brain. 
Or  a  large  area  of  bone  may  be  removed  from  the  cranium,  relieving 
the  ventricular  pressure  by  allowing  hernia  cerebri  as  in  the  operation 
of  decompression  for  brain  tumor  (p.  589). 

Congenital  Hydrocephalus. — In  these  cases  there  is  no  obstruction 
or  obliteration  of  the  foramina  at  the  base  of  the  brain,  but  for  some 
reason  the  cerebrospinal  fluid  collects  in  excessive  quantities,  and 
as  this  condition  supervenes  in  fetal  existence,  or  soon  after  birth 
before  the  cranium  is  ossified,  there  are  no  symptoms  of  cerebral 
compression,  but  progressive  enlargement  of  the  cranium  occurs, 
and  the  typical  hydrocephalic  head  is  produced  (Fig.  607).     A  fair 


556  SURGERY  OF   THE  HEAD 

degree  of  intelligence  may  be  preserved,  but  in  cases  of  extreme 
deformity  the  size  and  weight  of  the  head  may  render  the  child  help- 
less, and  in  most  cases  death  from  malnutrition  occurs  within  the 
first  two  years  of  life.  Spina  bifida  sometimes  complicates  the  case, 
and  paralyses  of  the  limbs  are  not  uncommon.  Rarely  is  the  disease 
arrested  spontaneously. 


Fig.  607. — Congenital  inteinal  hydrocephalus  of  moderate  grade.     Age  seventeen 
months.     Episcopal  Hospital. 

Treatment. — Keen  (1891)  and  Sutherland  and  Cheyne  (1898) 
attempted  to  drain  the  ventricles  into  the  subarachnoid  space  (intra- 
cranial drainage),  whence  they  thought  the  fluid  could  readily  be 
absorbed  by  the  veins  which  discharge  into  the  longitudinal  sinus. 
Cheyne  used  strands  of  catgut  for  this  purpose,  and  others  have 
used  various  materials,  including  gold  and  silver  tubes.  N.  Senn 
(1903)  drained  into  the  siihcuianeous  tissues.  But  the  immediate 
mortality  was  unduly  high,  and  no  permanent  benefit  was  secured 
in  those  patients  who  recovered,  so  that  the  operation  has  been 
abandoned.  Gushing  (1908),  having  due  regard  for  the  fact  that 
in  these  congenital  cases  there  rarely  is  any  obstruction  to  the  circula- 
tion of  the  cerebrospinal  fluid  at  the  base  of  the  brain,  inferred  thence 
that  the  obstruction  must  be  where  the  cerebrospinal  fluid  enters 
the  blood  vascular  system  {i.  e.,  in  the  region  of  the  longitudinal 
sinus) ;  on  this  account  he  held  it  to  be  useless  to  attempt  to  establish 
an  outflow  by  Keen's  and  Cheyne's  method;  but  he  proposed,  after 
ascertaining  that  the  ventricles  could  be  drained  by  puncture  of  the 
lumbar  spine,  to  divert  the  fluid  thence  into  the  retro-peritoneal 
tissues  by  means  of  a  silver  tube  passed  through  the  body  of  one  of  the 
lumbar  vertebrae.  He  has  done  this  operation  twelve  times  "with  a 
considerable  measure  of  success."  Heile  (1910),  in  an  infant  of  two 
days  old,  successfully  employed  Handley's  operation  (p.  270),  con- 
necting the  sac  of  a  spina  bifida  with  the  peritoneal  cavity  by  means 
of  subcutaneous  silk  threads;  a  complicating  hydrocephalus  also 
disappeared.     On  the  theory  that  the  excess  of  cerebrospinal  fluid 


INJURIES  OF  THE  SKULL  bbl 

is  not  due  to  (laiuiiiiiij,'  up  hut  to  liyiuTsecretion,  Stiles  (1905)  has 
practised  ligation  of  both  common  carotid  arteries,  at  an  interval  of 
three  weeks,  and  feels  encouraged  hy  the  results. 

INJURIES  OF  THE  SKULL. 

Wounds. — Occasionally  one  sees  incised  wounds  of  the  cranial 
bones,  without  fracture;  sabre  wounds  sometimes  occur  in  war,  and 
in  civil  life  a  pen-knife  or  other  sharp  instrument  may  be  stuck 
into  the  skull.  Such  injuries  require  no  special  treatment  beyond 
removal  of  the  foreign  body,  if  still  present,  and  antiseptic  care  of 
the  wound.  If  the  implement  is  so  firmly  embedded  in  the  skull  that 
it  cannot  be  withdrawn,  as  was  the  case  with  a  pen-knife  wound  of 
the  skull  which  I  treated  when  interne  at  the  P'piscopal  Hospital  (the 
point  of  the  blade  having  broken  off),  and  if  it  is  certain  that  the 
cranial  cavity  has  not  been  penetrated,  it  will  be  safe  to  wait  a  few 
hours  until  reactive  processes  in  the  surrounding  bone  have  begun, 
when  the  implement  may  be  extracted  easily.  Otherwise  the  surround- 
ing bone  must  be  removed  with  gouge,  and  the  object  extracted. 

Fractures. — For  practical  purposes  the  skull  may  be  considered 
a  sphere,  possessed  of  a  considerable  degree  of  elasticity.  For  it 
to  be  fractured,  a  good  deal  of  force  is  necessary,  and  this  acts  in  two 
main  ways:  (1)  the  skull  may  be  compressed  between  two  diametric- 
ally opposite  forces,  or  (2)  it  may  be  struck  a  violent  blow.  In  the 
latter  case  the  effect  is  the  same  whether  the  head  is  struck,  or  whether 
it  strikes  against  another  object;  the  only  counter-pressure  in  the 
former  case  is  that  offered  by  the  inertia  of  the  head  and  the  resist- 
ance of  its  attachments  to  the  trunk,  while  in  the  latter  there  is  also 
the  momentum  of  what  Archibald  happily  terms  the  "after-coming 
head."  Between  the  diffused  crush  and  the  localized  blow,  there 
may  be  all  grades  of  violence,  varying  from  the  puncture  made  by  a 
pick-axe,  or  the  blow  from  a  black-jack,  to  a  knockout  by  a  sand-bag, 
or  a  crush  between  two  heavy  beams. 

When  the  cranium  is  compressed  in  one  diameter  it  naturally 
expands  in  the  diameter  at  right  angles  to  the  first  (Saucerotte, 
1769);  Victor  Bruns  (1854)  and  Angus  McLean  (1912)  measured  this 
compensatory  expansion  experimentally,  finding  that  it  amounted 
to  several  millimeters.  The  first  and  most  obvious  result  of  this 
compression  was  illustrated  by  Ali  Krogius  (1907)  by  cracking  a 
hazelnut  by  lateral  compression  (Fig.  608):  fissures  are  produced 
which  represent  meridians  of  longitude  in  relation  to  the  points  of 
compression  w^hich  are  regarded  as  poles;  these  fissures  gape  widest 
in  the  equatorial  region,  and  when  compression  is  relaxed  they  may 
close  again  completely.  In  the  skull  such  fissures  are  very  frequently 
seen  as  the  result  of  diffused  violence,  and  in  them  may  be  caught, 
as  in  a  vise,  hairs  from  the  scalp,  portions  of  felt  from  a  hat,  and 
strangest  of  all,  foreign  bodies  may  even  pass  through  the  fissure  while 
it  momentarily  gapes,  and  thus  be  entirely  hidden  from  view  inside 


558 


SURGERY  OF   THE  HEAD 


the  cranium  when  the  closed  fissure  is  examined  by  the  surgeon. 
These  are  called  hiirsiing  fractures  (von  Wahl,  1883). 

Another  result  of  the  compensatory  expansion  of  the  skull  in  the 
diameter  at  right  angles  to  that  in  which  it  is  compressed,  is  that  at 
the  poles  there  occurs  an  inbending  of  the  skull  (Figs.  609  and  610); 
that  such  should  be  the  case  at  the  point  of  impact  of  localized  vio- 
lence, is  not  difficult  to  understand,  but  that  a  fracture  from  inbend- 
ing may  occur  at  a  point  more  or  less  remote  would  be  luithinkable 
unless  the  elasticity  of  the  skull  and  ordinary  physical  laws  were 
kept  in  mind.  This  is  the  fracture  by  counter-stroke  (contrecoitp) , 
which  formerly  was  explained  solely  on  the  basis  of  vibrations  which 
were  set  up  by  the  blow,  and  spreading  in  all  directions  from  the 


Fig.  60.S. — Mer-hanism  of  fracture 
of  the  skull  by  lateral  compression: 
a  meridional  bursting  fracture. 


Fig.  609. — Diagram  to  illustrate  the  elas- 
ticity of  the  skull.  When  the  skull  is  com- 
pressed between  a  and  b,  these  points  ap- 
proach each  other  while  the  points  c  and  d 
become  more  widely  separated.  (See  Fig. 
609.) 


Fig.  610. — Mechanism  of  fracture  of  the 
skull  by  counter-stroke:  when  the  skull  is 
compressed  at  a,  a  and  b  approach  each 
other,  and  a  fracture  by  inbending  maj'  occur 
at  b  as  well  as  at  a;  or  fracture  by  outbending 
may  occur  at  c  or  at  d. 


point  of  impact  met  finally  at  the  polar  point  and  there  disrupted 
the  skull.  Though  the  bursting  theory,  originated  by  Chopart  and 
other  French  surgeons  in  the  eighteenth  century,  and  re-introduced 
and  elaborated  by  Felizet  in  France  (1873),  by  Messerer  and  von 
Wahl  in  Germany,  and  by  Dulles  in  America,  in  the  eighth  decade 
of  the  last  century,  has  largely  superseded  the  vibratory  theory  as 
an  explanation  of  fissured  fractures  and  fractures  by  counter-stroke, 
there  can  be  no  doubt,  as  pointed  out  by  Xancrede  (1884),  that 
vibrations  do  occur,  and  are  most  violent  where  the  bone  is  thickest, 
that  is,  at  the  base  of  the  skull,  where  most  of  the  fractures  by 
counter-stroke  occur. 

When  localized  violence  is  applied  to  the  skull  the  force  of  the 
blow  expends  itself  mostly  by  depressing  the  bone  at  the  point  struck; 


INJURIES  OF  THE  .SKILL 


r)5<) 


this  is  the  inhnuliiig  frnriiire  referred  to  above.  Now,  this  j)oiiit 
l)eiii<;  rej^'iirded  as  a  pok',  there  are  j)r<)(hiced  in  the  surrouiidiiijf 
inert  l)iit  ehistic  skull,  eoneeiitric  areas  of  eompression,  or  outbrnditu/.s, 
which  rei)rescnt  parallels  of  latitude;  and  at  the  points  where  the 
inhending  and  outhending*  areas  meet,  a  circular  fissure  or  ring 
frdcfurr  may  result  (Fig.  (111). 
Occasionally  a  long  fissure  oc- 
curs at  the  ('(juatorial  region 
when  the  skull  is  flifi'usely 
crushed,  and,  according  to 
Archihald,  this  must  he  ex- 
plained as  a  fracture  by  out- 
bending,  as  must  certain  fis- 
sures which  run  at  right  angles 
to  the  meridional  bursting  fis- 
sures (Fig.  ()12). 

In  addition  to  the  usual  clas- 
sification of  fractures,  as  simple, 
compound,  depressed,  etc., 
there  are  important  clinical  dis- 
tinctions between  fractures  of 
the  vault  of  the  skull  and  those 
of  its  ba.se. 

Fractures  of  the  Vault  of  the  Skull. — ]\Iost  fractures  of  the  vault 
are  due  to  direct  violence,  the  parietal  and  temporal  bones  being 
most  often  injured.    Almost  always  the  injury  acts  from  outside  the 


^»^ 


Fig.  611. — Ring  fracture  of  skull.  From 
a  specimen  in  the  Mutter  Museum  of  the 
College  of  Physicians  of  Philadelphia. 


Fig.  612. — Burstinj;  fracture  of  skull  from  diffused  violence  on  vertex:  fissure  radiating 
to  base  and  widest  at  equator  (temporal  region) ;  with  outbending  fracture  (just  below- 
parietal  eminence)  at  right  angles  to  main  fissure.  From  a  specimen  in  the  Mutter 
Museum. 

skull,  SO  that  the  inner  table  is  in  the  line  of  extension  (Fig.  613), 
and,   therefore,    is   more   widelv   fractured   than   the   external  table 


^  The  Flachbiegung  unci  Krumbiegung  of  Treub  (1884). 


560 


SURGERY  OF   THE  HEAD 


;,a^^^^l 


^^fe**:-. 


t^^^e^^^^^c^,;^;^'^^.?^*^ 


Fig.  613. — Teevan's  diagram  to  show 
that  the  inner  table  often  is  more  exten- 
sively damaged  than  the  external,  because 
it  is  in  the  line  of  extension. 


(Teevan,  1864).  Indeed,  so  elastic  is  the  skullthat  a  fracture  of  the 
vitreous  table  may  occur  without  any  fracture  of  the  outer  table. 
In  the  rare  cases,  mostly  suicidal  pistol  shots,  in  which  the  cranial 
vault  is  fractured  from  violence  within  the  skull,  the  outer  table  is 
more  widely  fractured  than  the  inner.     It  is  very  unusual  for  the 

external  table  to  be  fractured 
without  injury  of  the  internal; 
it  is  then  depressed  into  the 
diploe.  In  1909  I  trephined  for 
such  an  injury,  in  a  boy,  aged 
thirteen  years,  at  the  Episcopal 
Hospital,  Philadelphia.  The 
amount  of  splintering  is  in  in- 
verse ratio  to  the  momentum 
of  the  body  fracturing  the  skull; 
but  in  the  case  of  gunshot 
wounds,  as  pointed  out  at  p. 
188,  the  "explosive  action"  is 
manifested  at  close  range. 

Symptoms. — Apart  from  those 
due  to  intracranial  complications 
(p.  569),  there  are  no  symptoms  specially  indicative  of  a  fracture  of 
the  vault  of  the  skull.  The  diagnosis  rests  on  the  history  of  injury, 
on  the  symptoms  due  to  complicating  intracranial  lesions,  and  on 
physical  signs.  A  skiagraph  may  be  of  value.  If  there  is  no  scalp 
wound,  the  entire  calvaria  must  be  palpated  carefully  and  persistently 
to  discover  any  evidence  of  fracture;  if  a  mere  fissure  exists,  without 
depression  or  separation,  nothing  will  be  detected  beyond  the  signs 
of  contusion  of  the  scalp  (p.  551).  The  error  of  mistaking  a  hema- 
toma for  a  depressed  fracture  must  be  guarded  against.  If  there  is  a 
depressed  fracture  it  usually  is  possible  to  feel  it  tlirough  the  scalp, 
recognizing  its  jagged  outline  and  its  actual  depression  below  the 
surrounding  bony  surfaces;  the  depressed  fragments  may  not  be 
impacted,  and  injudicious  pressure  may  drive  them  against  the  brain. 
If  the  existence  of  a  fracture  remains  in  doubt,  no  hesitancy  should 
be  felt  in  making  an  incision  down  to  the  bone,  under  proper  anti- 
septic precautions,  and  inspecting  the  bared  cranium.  In  compound 
fractures  it  may  be  necessary  to  enlarge  the  existing  wound  for  the 
same  purpose.  A  normal  suture  may  be  distinguished  from  a  fissured 
fracture  by  its  anatomical  position,  its  greater  irregularity  of  outline, 
and  by  the  fact  that  a  fracture  cannot  be  washed  clean  of  blood. 
In  children  there  may  be  diastasis  of  suture  lines  instead  of,  or  in 
addition  to,  fissured  or  depressed  fracture  of  the  skull. ^ 

Prognosis. — This  is  good,  so  far  as  the  fracture  alone  is  con- 
cerned. It  is  only  intracranial  complications  that  render  the  outcome 
doubtful.  Excessive  loss  of  bone  seldom  occurs,  and  complications 
affecting  the  scalp  (erysipelas,  etc.)  are  very  rare  with  antiseptic 
methods. 

^See  footnote,  p.  561. 


ISJIRIES  OF   THE  SKILL  'yiW 

Trcdfinrnf. — EvtTv  case  of  liead  injury,  no  matter  how  trivial  in 
appearance,  should  he  treated  with  extreme  circumspection.  It 
is  the  custom  of  many  cautious  surjjeons,  and  for  .\-ears  has  been 
mine,  to  urjije  all  patients  with  injuries  of  the  head  to  remain  under 
constant  surgical  observation,  preferably  in  the  hospital,  for  several 
days.  It  is  most  important  to  prevent  infection;  and,  as  a  rule,  it  is 
well  to  shave  the  entire  scalp,  as  this  often  renders  diagnosis  easier, 
and  always  promotes  asei)sis.  Shaving  the  scalp,  or  at  least  a  wide 
area  around  the  injury,  therefore,  usually  is  the  first  step  in  treatment. 

//  onI}/  a  fdinpJr  fissured  fracture  exists,  without  depression,  and 
without  any  c\idcnce  of  intracranial  mischief,  it  is  sufficient  to  keep 
the  j)atient  in  bed  for  six  to  eight  days,  with  an  ice  l)ag  to  the  head; 
the  bowels  should  be  well  opened,  preferably  by  calomel,  as  this 
has  a  specific  action  upon  the  meninges  and  brain,  exerting  w^jat 
was  known  in  the  last  century  as  an  "anticipatory  antiplastic  action," 
that  is,  pre\enting  excessive  inflammatory  reaction,  probably  by 
its  antiseptic  properties.  Urotropin  is  used  for  the  same  purpose, 
as  it  has  been  found  to  circulate  in  the  cerebrospinal  fluid;  it  must 
be  given  in  very  large  doses.  If  the  simple  fissured  fracture  was 
caused  by  localized  violence,  which  is  rarely  the  case,  it  will  be  safer 
to  ascertain  whether  or  not  the  inner  table  is  splintered,  by  removing 
a  button  of  bone  with  the  trephine.  If  such  splintering  exists,  the 
case  is  treated  as  a  depressed  fracture. 

If  the  fissured  fracture  is  compound  the  surgeon  should  make  very 
certain  that  no  hair  or  other  foreign  body  is  caught  in  the  fissure, 
or  has  passed  through  it,  before  he  decides  against  operation.  If 
there  is  any  doubt  as  to  the  surgical  cleanliness  of  the  fissure,  the 
surgeon  must  take  means  to  render  it  aseptic  as  soon  as  the  patient 
recovers  from  the  shock  of  the  accident.  Sometimes  little  tufts  of 
hair  are  found  sticking  up  out  of  almost  invisible  fissures  (G.  G. 
Davis,  1910),  and  a  gouge  must  be  employed  to  remove  them  and 
their  containing  bone;  in  other  cases  a  trephine  may  be  used  to  per- 
forate the  skull,  and  then  the  entire  septic  fissure  is  gnawed  away 
into  healthy  bone  by  rongeur  forceps.' 

//  the  fracture  is  depressed  I  believe  operation  always  in  indicated, 
to  relieve  pressure  on  the  brain;  and  if  it  is  compound,  whether  it  is 
depressed  or  not,  operation  usually  is  necessary  to  secure  asepsis  of 
the  wound.  But  operation  has  no  virtue  of  its  own,  being  only  a 
mechanical  means  of  fulfilling  plain  therapeutic  indications.     Loose 

'  In  1907  I  operated  on  a  boy  of  eleven  years,  at  the  Episcopal  Hospital,  Phila- 
delphia, for  extensive  bursting  fracture  due  to  crush;  there  were  compund  com- 
minuted depressed  ring-fractures  in  the  right  parietal  and  the  left  temporal  bones, 
the  poles  of  impact;  and  these  areas  were  connected  across  the  vault  by  a  meridi- 
onal fissure  which  was  deflected  into  the  suture  lines,  causing  diastasis  of  the  right 
temporo-parietal  suture  and  the  entire  coronal  suture,  with  rupture  of  the  long- 
tudinal  sinus.  The  loose  fragments  were  removed,  the  depressed  fragments 
elevated,  and  the  separated  sutures  cleaned  of  hairs  and  clot  by  gnawing  away 
both  margins  of  bone.  From  the  left  temporal  region  a  fissure  ran  to  the  base, 
thus  practically  separating  the  skull  into  antero-posterior  halves.  There  was 
no  injury  to  the  brain,  and  the  boy  recovered. 
36 


502 


SURGERY  OF   THE  HEAD 


fragments  are  removed,  and  the  elevator  (Fig.  614,  3)  is  passed  under 
the  depressed  fragments  and  these  are  pried  up  into  place.  Search 
is  then  made  by  Horsley's  dural  separator  (Fig.  614,  2)  for  loose  frag- 
ments which  sometimes  are  driven  under  the  neighboring  intact  por- 
tions of  cranium,  and  these  are  removed.  All  fragments  completely 
detached  should  be  removed  entirely;  they  will  not  reunite  if  left  in 
place,  and  may  undergo  necrosis  or  cause  infection.  At  best  they 
would  act  only  as  decalcified  bone  might,  as  an  inorganic  basis  into 
which  surrounding  osteoblastic  cells  might  grow.  If  the  fragments  are 
impacted,  so  that  none  of  them  can  be  removed,  and  there  is  no  crack 
into  which  the  elevator  can  be  insinuated,  a  button  of  bone  must 


Fig.  614. — Instruments  used  in  operating  for  fracture  of  the  skull:  1,  Crown  trephine; 
2,  Horsley's  dural  separator;  3,  bone  elevator;  4,  Hopkins's  rongeur  forceps. 


be  removed  by  the  crown  trephine  (Fig.  614,  1),  and  the  remaining 
depressed  fragments  ele\'ated  through  the  opening  thus  made.  Next, 
the  bone  must  be  disinfected.  Usually  this  is  best  accomplished  by 
biting  oflF  ragged  edges  of  bone  with  the  rongeur  forceps  (Fig.  614,  4), 
thus  completely  removing  all  suspicious  areas  in  which  foreign  par- 
ticles may  have  been  caught.  In  fractures  of  the  frontal  siiwses  the 
outer  w^all  alone  may  be  fractured;  but  as  the  sinuses  are  of  uncer- 
tain extent,  even  when  developed,  and  as  the  fracture  always  is 
compound,  either  from  within  or  on  the  skin  surface,  it  is  proper 
to  explore  the  region  affected,  and  to  remove  sufficient  bone  to  render 
the  wound  surgically  clean. 

After  any  operation  for  fracture  of  the  skull,  a  copious  dressing 


INJURIES  OF  THE  SKULL 


o(J3 


should  be  securely  applied  (Fig.  015),  as  the  patient  may  he  delirious, 
and  reciuires  mechanical  protection  to  the  site  of  operatif)n. 

liupturc  of  the  longitudinal  sinus  is  a  not  infrc(iuent  complication 
of  fractures  of  the  cranial  vault.  H.  K.  Wharton  (1901)  collected 
70  case  reports.  Bone  fragments  may  be  embedded  in  its  walls, 
or  it  may  be  torn  accidentally  in  elevating  or  removing  depressed 
fragments.  Hemorrhage  may  be  profuse,  but  it  is  readily  controlled 
by  packing,  as  the  blood-pressure  is  low.  Attempts  to  suture  the 
rent  rarely  are  successful,  the  sutures  tearing  out;  and  the  profuse 
hemorrhage  may  cost  the  patient  his  life  before  the  attempts  to  suture 
are  abandoned.  Packing  is  quicker  and  safer.  The  gauze  should  be 
removed  in  three  or  four  davs. 


^ 

■ 

Fit:.  61.5. — Dressing  for  fracture  of  skull.      Episcopal  Hosijital. 

Trephining  the  Skull. — The  trephine  is  applied  first  with  the  centre- 
pin  protruded;  with  this  as  a  pivot  a  circular  groove  is  cut  by  alter- 
nately supinating  and  pronating  the  hand,  and  when  this  groove  is 
of  sufficient  depth  to  steady  the  trephine  without  the  aid  of  the 
centrepin  this  is  withdrawn,  and  the  trephining  is  continued  very  cau- 
tiously, using  scarcely  any  pressure  for  fear  of  plimging  the  instru- 
ment into  the  brain.  The  use  of  Gait's  conical  trephine'  renders  this 
accident  unlikely,  if  ordinary  prudence  is  exercised.  When  the 
diploe  is  reached,  the  trephine  cuts  more  easily,  and  the  bone  bleeds 
more;  as  the  vitreous  is  approached  the  surgeon,  from  time  to  time, 
should  test  the  depth  of  his  groove  with  the  fiat  end  of  a  probe,  as 
the  skull  is  not  of  uniform  thickness  and  incautious  trephining  may 
rupture  the  dura  at  one  side  before  the  vitreous  table  is  cut  through 
on  the  other.  If  the  button  of  bone  does  not  come  away  in  the  crown 
of  the  trephine,  it  is  pried  out  by  the  elevator.  The  trephine  never 
should  be  applied  on  the  depressed  fragment,  but  on  the  surrounding 
intact  cranium,  so  that  no  further  impaction  or  cerebral  injury  may 
be  produced.  Nor  should  the  trephine  be  applied  directly  over  the 
longitudinal  or  lateral  sinuses. 

Hudson  s  Trephine  (1909)  is  a  modification  of  Doyen's  burr  (1896), 
an  instrument  like  a  carpenter's  brace  and  bit;  the  burrs  of  Hudson's 

1  Thi.s  was  a  revival  of  an  old  instrument.  Gait's  pattern  was  first  used  by 
Sayre  in  1861 :  the  spiral  grooves  on  the  periphery  act  as  a  wedge  so  long  as  there 
is  counter-pressure  by  bone  on  the  oblique  teeth  of  the  crown;  when  resistance 
ceases,  the  spiral  grooves  act  as  a  screw,  and  the  trephine  binds.  Hudson's 
trephine  (p.  588)  is  constructed  on  the  same  principle. 


5()4 


SURGERY  OF   THE  HEAD 


instrument  (Fig,  628)  are  made  with  spiral  cutting  grooves,  so  that 
unless  something  solid  like  bone  is  pressed  upon  by  the  point,  the 
instrument  will  bind,  thus  rendering  imj)ossible  an  injury  to  the 
dura.  This  is  the  same  principle  on  which  Gait  constructed  his 
conical  trephine. 

Fractures  of  the  Skull  in  the  Newborn. — Indentations  of  the  semi- 
membranous skull  of  the  baby  may  occur  from  injury  during  labor, 
or  at  a  later  age  from  blows,  falls,  etc.  The  bone  is  so  flexible  that 
true  fracture  during  labor  is  rarer  than  bending.  The  depression 
usually  corrects  itself  within  ten  days;  if  it  does  not,  and  immediately 
if  it  produces  symptoms  of  cerebral  compression  (p.  570),  operation 
should  be  done.  Nicoll's  operation  (190.S)  consists  in  excision  of  the 
cup-shaped  depression,  and  its  replacement  with  the  dural  (convex) 
surface  beneath  the  skin.  Usually  it  is  sufficient  to  pry  the  bone 
up  by  an  elevator  introduced  through  a  neighboring  fontanelle  or 
suture.  The  bone  is  soft  and  easily  cut  by  scissors.  Some  surgeons 
use  a  corkscrew  for  an  elevator.  The  danger  of  leaving  such  fractures 
untreated  is  that  cortical  lesions  may  result,  leading  to  spastic  par- 
alysis, epilepsy,  imbecility,  etc.  Commandeur  (1910)  has  collected  46 
such  operations,  with  three  deaths  from  infection.  In  older  infants 
fracture  may  split  the  cranial  bone  radially  in  the  usual  line  of 
ossification. 

Fractures  of  the  Base  of  the  Skull.— Most  of  these  are  the  result  of 
bursting  force,  a  fissure  extending  from  the  point  of  injury  on  the 

vault  to  the  base  of  the  skull,  usually 
along  definite  lines.  The  recognition 
of  this  fact  is  due  chiefly  to  Aran 
(1844),  who  claimed  that  in  every 
fracture  of  the  base  the  fissure 
began  in  the  vault.  This,  how- 
ever, is  not  literally  true,  as  the 
fracture  sometimes  begins  at  the 
base  and  may  or  may  not  extend 
to  the  vault.  Falls  on  the  feet  or 
on  the  buttocks  may  fracture  the 
base  by  force  applied  through  the 
condyles  of  the  occipital  bone. 
When  fracture  of  the  base  occurs 
as  part  of  a  bursting  fracture  from 
diffused  force  applied  to  the  cah-aria, 
the  fissure  extends  to  the  base  by 
the  shortest  anatomical  route, 
avoiding  buttresses  such  as  the 
mastoid,  the  external  angular  pro- 
cess of  the  frontal  bone,  etc.  Thus 
it  is  found  that  in  fractures  from  lateral  compression,  usually  on  the 
parietal  bones,  the  fissure  crosses  the  middle  fossa  of  the  skull  in  the 
majority  of  cases  (23  out  of  32  cases  recorded  by  Archibald).     From 


Fig.  61G.  —  Diagram  allowing  the 
usual  course  taken  by  fissured  fractures 
of  the  base  of  the  skull. 


INJURIES  OF  THE  SKULL  565 

occi pita-frontal  compres.s'ion,  a  fissure  results  which  passes  usually 
thr()U<:;h  oue  orbital  plate  of  the  frontal,  through  the  body  of  the 
sj)iuMioi(l,  and  the  sella  turcica,  along  the  petro-occipital  suture  to 
the  jugular  foramen,  and  perhaps  up  again  to  the  vault  along  the 
niasto-occipital  suture;  or  if  the  fissure  passes  down  the  occipital 
bone,  it  skirts  the  side  of  the  foramen  magnvnii,  and  so  to  the  sella 
turcica  (Fig.  ()1()).  Uawling  found  the  sphenoidal  sinus  fractured  in 
70  per  cent,  of  his  cases.  These  basal  fractures  very  often  are  com- 
pound, through  the  nas()-i)harynx  or  middle  ear.  Displacement  is 
very  slight. 

Punctured  fractures  of  the  base  of  the  skull  are  exceedingly  serious 
lesions;  they  occur  from  such  implements  as  umbrella  tips,  pencils, 
pipe-stems,  etc.,  which  may  penetrate  the  orbit  or  naso-pharynx, 
sometimes  entering  one  of  the  fissures  or  foramina  at  the  base  of  the 
brain  with  little  damage  to  the  surrounding  bone. 

Symptoms. — These  depend,  as  in  fractures  of  the  vault,  much 
more  upon  cerel^ral  injury  than  upon  the  mere  existence  of  fracture. 
The  diagnosis,  therefore,  depends  in  large  measure  on  circumstantial 
evidence  derived  from  certain  physical  signs,  and  from  a  knowledge 
of  the  mode  of  injury.  Fractures  of  the  anterior  fossa  may  be  accom- 
panied by  bleeding  into  the  retrobulbar  tissues  of  the  orbit,  sub- 
conjuncti\al  ecchymosis  appearing  some  days  after  the  injury,  and 
spreading  from  behind  forward;  exophthalmos  is  a  rare  sign.  Bleed- 
ing from  the  nose  or  mouth  is  as  often  due  to  extracranial  as  to  cranial 
lesions.  Brain  substance  or  cerebrospinal  fluid  rarely  is  discharged. 
Blood  may  be  swallowed  and  vomited.  Fractures  of  the  middle  fossa 
frequently  are  compound  through  the  middle  ear,  and  though  bleed- 
ing from  the  ear  may  be  due  merely  to  rupture  of  the  tympanic  mem- 
brane, when  persistent  or  profuse  it  has  usually  an  intracranial  source ; 
it  may  enter  the  throat  through  the  Eustachian  tube.  A  clear  liquid 
discharge  may  occur  from  the  mastoid  cells  or  from  the  membranous 
labyrinth,  but  any  such  discharge  in  large  amount  is  more  apt  to  be 
cerebrospinal  fluid.  Paralysis  of  one  or  more  of  the  cranial  nerves 
is  more  frequent  in  fractures  of  the  middle  fossa  than  in  those  of 
the  anterior  or  posterior  fossa^.  The  seventh  and  eighth  nerves  are 
those  most  often  injured,  usually  from  laceration  or  secondary  edema. 
Ferron  (1908)  collected  339  instances  of  nerve  lesion,  with  33  deaths. 
Fractures  of  the  posterior  fossa  frequently  are  not  recognized,  because 
of  lack  of  physical  signs.  Ecchymosis  over  the  mastoid,  appearing 
some  days  after  the  injury,  is  of  some  significance;  as  is  the  occasional 
involvement  of  the  ninth,  tenth,  and  eleventh  nerves. 

Prognosis. — This  depends  upon  the  presence  of  intracranial  lesions 
and  upon  the  development  of  complications,  especially  meningitis. 
Without  these,  the  prognosis  is  no  worse  than  in  fracture  of  the 
vault.  As  a  general  rule,  about  one  out  of  three  or  four  patients 
with  fracture  of  the  base  will  die  within  a  week  or  ten  days. 

Treatment.— The  general  treatment  is  the  same  as  in  fractures 
of  the  vault:  physical  and  mental  rest,  in  a  cool,  darkened  room; 


500 


SURGERY  OF   THE  HEAD 


and  purgation  to  remove  material  which  might  cause  toxemia  or  bac- 
teremia and  hence  increase  the  danger  of  sepsis.  Urotropin  should 
be  administered  (15  grains  tliree  times  daily,  with  an  interval  of  one 
day  at  the  end  of  each  three-day  period),  and  liquid  diet  should  be 
continued  until  danger  of  complications  has  passed.  The  naso-pharynx 
and  external  auditory  meatus  should  be  cleansed,  but  repeated 
irrigation  is  more  apt  to  encourage  sepsis  than  to  prevent  it.  If 
bleeding  is  profuse  it  may  be  necessary  to  pack  the  naso-pharynx 
or  auditory  meatus;  in  all  cases  it  is  well  to  keep  a  little  sterile  ab- 
sorbent cotton  in  the  latter  channel  to  absorb  discharges.  If  bleeding 
is  very  persistent,  and  especially  if  packing  produces  symptoms  of 
cerebral  compression,  attempt  should  be  made,  by  trephining  the 
skull  low  in  the  temporal  region,  to  reach  the  source  of  hemorrhage 
and  deal  directly  with  it.  If  symptoms  of  compression  arise,  whether 
there  is  external  hemorrhage  or  not,  decompression  should  be  done 
(p.  589).  Nassau  (1912)  not  only  does  decompression,  but  opens  the 
dura,  and  lightly  packs  the  arachnoid  spaces  with  gauze;  he  claims 
that  this  is  the  only  efficient  method  of  controlling  intradural  hemor- 
rhage (p.  575).  Four  days  later  the  patient  is  again  anesthetized,  the 
gauze  is  removed,  the  dural  flap  sutured,  and  the  scalp  closed.  Lumbar 
puncture  may  be  employed  as  a  diagnostic  measure  to  ascertain  the 

presence  of  blood  in  the  cerebrospinal 
fluid;  occasionally  it  is  curative  also. 

Osteomyelitis. — Osteomyelitis  of  the 
cranial  bones  is  rare,  and  extremely 
fatal ;  usually  it  follows  contusion  of  the 
bone,  secondary  infection  occurring 
through  the  blood-stream  or  from  an 
overlying  hematoma.  It  is  rarer  still 
as  a  complication  of  compound  fracture 
or  a  scalp  wound,  as  in  such  cases 
drainage  is  free.  The  diagnosis  rests  on 
the  appearance  of  septic  symptoms,  after 
injury  to  the  skull,  with  the  develop- 
ment locally  of  the  "puffy  tumor"  of 
Percival  Pott  (1708),  which  is  "a  circum- 
scribed, flattened,  elevated  swelling," 
due  to  infiltration  of  the  scalp  with 
serum,  and  indicates  "a  subjacent  sup- 
purative periosteitis,  denuded  bone,  and 
in  many  instances  subcranial  suppura- 
tion with  separation  of  the  dura  mater" 
(Nancrede,  1885). 
Treatment. — Treatment  consists  in  removal  of  all  diseased  bone, 
by  trephine  and  rongeur,  with  free  drainage.  Death  is  the  usual 
outcome  of  the  disease,  from  meningitis  and  encephalitis,  except 
where  very  early  operation  is  done. 


Fig.  617. — Loss  of  bone  after 
fractured  skull:  four  months  after 
operation.  (Dr.  Mutschler's 
case.)     Episcopal  Hospital. 


CRANIO-CKREHRA  L    TOI'Odh'A  I'll  Y  ')()7 

Repair  of  Cranial  Defects,  rsuallv  alter  operation  for  fracture 
or  other  lesion  of  tlie  skull,  in  which  a  lar^'c  area  of  hone  is  removed, 
the  defect  produces  little  inconvenience,  beinj;;  filled  in  by  dense 
fibrous  tissue.  Tliere  is  no  tendency  to  liernia  cerebri  (Fi^.  (iiil )  unless 
intracranial  tension  is  increased;  on  the  contrary,  the  area  usually 
is  depressed  (Fifj;.  ()17).  Sometimes,  from  dural  adhesions,  or  other 
cause,  this  depressed  area  is  a  source  of  constant  aimoyance,  and 
may  subject  the  brain  to  slight  injuries.  If  the  symptoms  are  so 
severe  as  to  d(>mand  relief,  a  pedunculated  osteoplastic  flap,  composed 
of  scalp  and  outer  table  of  the  skull,  may  })e  raised  by  chisel  from  the 
neighboring  healthy  bone,  and  implanted  into  the  defect  (Konig, 
IsyO),  the  denuded  cranium  being  covered  by  a  Wolfe  graft;  or,  as 
done  by  Frazier  in  a  recent  case  at  the  Episcopal  Hospital,  a  free 
trans])lant,  consisting  of  the  outer  table,  may  be  removed  from 
another  portion  of  the  skull. 

SURGICAL  AFFECTIONS  OF  THE  BRAIN  AND  MENINGES. 

Cranio-cerebral  Topography,  which  implies  a  knowledge  of  the 
relation  of  intracranial  structures  (cerebral  fissures  and  convolutions, 
blood-sinuses,  meningeal  vessels,  etc.)  to  the  overlying  skull,  is  not 
now  regarded  as  of  so  much  importance  as  some  years  ago.  This 
is  so  both  because  these  relations  exhibit  variations  in  different 
persons,  and  because  modern  surgical  technique  enables  the  surgeon 
to  raise  a  large  bone  flap  from  the  cranium,  and  expose  the  underlying 
structures  over  a  sufficiently  wide  area  to  permit  of  his  recognizing 
them  rather  by  their  relations  to  each  other  than  by  their  relations 
to  the  surface  of  the  cranium.  But  there  are  a  few  landmarks  which 
it  is  indispensable  for  the  surgeon  to  know. 

The  longitudinal  simis  runs  beneath  the  sagittal  suture  from  the 
root  of  the  nose  to  the  inion;  it  lies  within  the  falx  cerebri,  and  extends, 
with  its  annexed  blood-lakes,  for  nearly  an  inch  each  side  of  the 
median  line,  being  broader  behind  than  anteriorly.  Usually  it  extends 
further  to  the  right  than  to  the  left  of  the  median  line. 

The  lateral  sinus  runs  on  each  side,  along  the  attachment  of  the 
tentorium  cerebelli,  from  the  inion  to  the  base  of  the  mastoid;  here 
it  passes  dowmward,  following  the  petro-mastoid  suture  to  the  jugular 
foramen  (Fig.  ()19).  The  anterior  and  upper  margin  of  the  curve 
wdiere  the  horizontal  and  descending  (sigmoid)  portions  of  the  lateral 
sinus  meet,  known  as  the  knee  (genu)  of  the  lateral  sinus,  is  about 
2.5  cm.  (1  inch)  above  and  nearly  4  cm.  (about  1^  inches)  behind  the 
centre  of  the  external  auditory  meatus.  The  sinus  is  about  12  mm. 
(I  inch)  or  more  broad,  and  the  "dangerous  area,"  over  which  a  tre- 
phine or  chisel  should  not  be  applied,  includes  a  strip  of  bone  nearly 
2.5  cm.  (1  inch)  wide,  overlying  the  course  of  the  sinus. 

The  upper  limit  of  the  cerebral  hemispheres  corresponds  to  the 
position  of  the  superior  longitudinal  sinus.  Their  lower  limit  reaches, 
in  front  to  the  upper  margin  of  the  orbit;  laterally  it  passes  from  a 


568 


SURGERY  OF   THE  HEAD 


point  12  mm.  (|  inch)  above  the  external  angular  process  of  the 
frontal  bone,  to  the  upper  margin  of  the  external  auditory  meatus, 
and  thence  to  the  inion,  along  the  upper  border  of  the  lateral  sinus. 

The  fissure  of  Rolando  runs  from  a  point  about  12  mm.  (|  inch) 
behind  the  mid-point  between  glabella  and  inion,  forward  for  nearly 
8.5  cm.  (8|  inches),  at  an  angle  of  about  70°  with  the  sagittal  suture. 
If  a  square  of  paper  (90°)  is  folded  diagonally,  so  as  to  make  two  angles 
of  45°  each,  and  one  of  these  folds  is  again  doul)led  on  itself,  so  as 
to  make  two  angles  of  22.5°  each,  it  will  be  possible,  by  adding  one 
of  these  latter  angles  to  the  45°  angle,  to  construct  off-hand  an  angle 
of  (')7.5°,  or  three-quarters  of  the  original  right  angle.     If,  then,  this 


Fig.  618. — Relation  of  the  chief  fissures  and  convolutions  of  the  brain  to  the  surface 
of  the  skull.  The  dotted  line  which  is  nearly  horizontal  indicates  the  fissure  of  S.vlv^ius; 
this  line  runs  from  the  external  angular  process  of  the  frontal  bone  through  a  point 
2  cm.  below  the  parietal  eminence  (x),  and  its  middle  third  corresponds  roughly  with 
the  Sylvian  fissure.     Note  the  positions  of  the  cranial  sutures. 


angle  (07.5°)  is  placed  on  the  sagittal  suture,  so  that  its  apex  lies 
12  mm.  (I  inch)  behind  the  mid-point  between  glabella  and  inion, 
the  course  of  the  Rolandic  fissure  will  be  approximately  indicated 
(Chiene,  1888).  The  relation  of  the  other  chief  fissures  and  con- 
volutions is  sufficiently  indicated  in  Fig.  ()18. 

The  middle  vieningeal  artery,  entering  the  skull  by  the  foramen 
spinosum,  divides  almost  immediately  into  two  branches.  The  anterior 
branch  runs  forw'ard  and  upward  and  crosses  the  anterior  inferior 
angle  of  the  parietal  bone,  near  the  pterion;  thence  it  runs  upward 
toward  the  sagittal  suture,  lying  behind  and  more  or  less  parallel 
to  the  coronal  suture.  Near  the  pterion  it  lies  usually  in  a  bony 
groove  or  canal,  and  is  frequently  torn  by  splinters  of  bone,  or  ruptured 


CONCUSSION  AND  CONTUSION   OF   THE  BRAIN  5G9 

\)\  iiilu'iidiii^'  or  l)iirstiiif,'  fractures  at  this  point.  It  may  also  be 
iiijuri'd  at  this  |)()iiit  1)\  a  trcpliiiie,  so  it  is  safer  to  expose  it  by  a 
trephine  openin*,'  in  the  niiddk'  of  tlie  temporal  fossa,  say  4  em. 
(1^  inches)  posterior  to  the  e.xternal  anj^ular  process  of  the  frontal 
bone,  and  2.5  cm.  (1  inch)  above  the  zygoma  (Fifj.  (ill)).  The  pos- 
terior branch  runs  iiori'/ontally  backward  across  the  scjuamous  plate 
of  the  tcni])oral  bone,  and  crosses  the  teniporo-i)arietal  suture  within 
about  2  cm.  (f  inch)  of  its  posterior  end;  it  may  be  exposed  by  a 
trephine  opening;  about  2. .5  cm.  (1  inch)  below  the  parietal  eminence. 


Fig.  619. — Course  of  middle  meningeal  artery  and  lateral  sinus,  outlined  upon 
the  surface  of  the  skull. 

Concussion  and  Contusion  of  the  Brain. — The  brain  is  an  incom- 
pressible structure  suspended  within  a  bony  case  by  fibrous  partitions, 
chief  of  which  are  the  falx  and  tentorium;  it  is  held  relatively  immobile 
at  its  base  by  the  cranial  nerves,  bloodvessels,  and  processes  of  dura 
mater,  which  pass  through  the  base  oi  the  skull.  It  is  surrounded  by 
a  small  amount  of  cerebrospinal  fluid,  which  is  in  greater  quantity 
toward  the  base,  especially  around  the  medulla;  and  its  ventricles, 
which  are  directly  continuous  with  the  subdural  spaces  (p.  555), 
are  filled  with  the  same  fluid.  A  blow  upon  the  head  causes  not  so 
much  a  vibration  or  tremefaction  of  the  brain  substance,  as  a  sudden 
displacement  of  the  brain  as  a  whole;  it  is  flung,  as  it  were,  against 
the  opposite  side  of  the  skull,  and  usually  it  is  contused  most  at  the 
point  of  impact,  or  the  polar  point,  or  at  the  base,  where  the  greatest 
strain  comes.  The  cerebellum  is  relatively  little  affected,  because 
of  its  protected  position  beneath  the  tentorium,  because  it  floats 
on  a  greater  amount  of  cerebrospinal  fluid,  and  because  of  the  possi- 
bility of  downward  displacement  by  crowding  the  medulla  into  the 
foramen  magnum.  Some  blows  on  the  head,  severe  enough  to  cause 
symptoms,  produce  symptoms  which  are  so  momentary  and  fleeting 
that  it  always  has  been  difficult  to  believe  that  they  were  attended 
by  structural  change.  And  until  modern  methods  of  histological 
study    were    developed,    it    happened    not    rarely    that    postmortem 


570  SURCERY  OF   THE  HEAD 

examination  failed  to  disclose  any  lesion  in  the  brains  of  those  who 
had  actually  died  with  symptoms  due  to  "concussion."  But  it  has 
come  to  be  recognized,  largely  through  the  investigations  of  Sir 
Prescott  Hewett  (1870),  that  the  condition  of  these  brains  is  not  one 
of  "concussion,"  as  was  formerly  taught,  but  is  the  result  of  con- 
cussion, and  is  characterized  by  contusion,  compression,  extravasation, 
laceration,  or  inflammation  in  varying  degrees.  Of  course,  it  cannot 
be  asserted  categorically  that  histological  changes  always  are  present 
in  patients  who  recover  at  once  from  the  symptoms  of  concussion, 
because  there  is  no  opportunity  of  submitting  their  tissues  to  micro- 
scopical examination  at  the  time  of  injury;  but  the  belief  is  quite 
general,  and  I  believe  quite  justified,  that  even  when  the  symptoms 
produced  are  the  most  insignificant,  definite  lesions  exist,  and  that 
these  vary  from  temporary  arrest  of  cell-action,  with  capillary  stasis, 
or  the  slightest  grades  of  contusion,  with  punctate  hemorrhages, 
to  distinct  laceration,  ecchymosis,  exudation,  and  edema  of  the 
brain  and  pia-arachnoid.  Kocher  teaches  that  the  immediate  and 
temporary  symptoms  are  the  result  of  cerebral  anemia,  while  uncon- 
sciousness which  lasts  for  hours  or  days  is  due  to  cellular  changes. 

Symptoms.-^As  in  all  cases  of  injury,  some  degree  of  shock  is 
present,  and  it  often  is  difficult  to  distinguish  the  symptoms  of  this 
condition  from  those  due  to  concussion  of  the  brain.  After  a  blow 
on  the  head  only  such  symptoms  as  dizziness,  or  disturbances  of 
vision  (sparks,  specks,  etc.),  may  be  observed.  In  more  marked 
cases  there  is  momentary  loss  of  consciousness,  the  patient  falling 
as  one  dead;  or,  when  striking  the  head  in  a  fall,  lying  motionless 
for  a  few  seconds,  and  then  regaining  consciousness  and  rising  to  his 
feet  before  assistance  can  reach  him.  In  typical  cases,  two  distinct 
stages  may  be  recognized:^  (1)  The  patient  at  first  lies  motionless, 
senseless,  nearly  pulseless,  pale  and  cold,  breathing  feebly  but  natur- 
ally; the  pupils  dilated  or  contracted,  fixed  or  acting  freely;  perhaps 
with  involuntary  discharge  of  feces  and  urine.  He  will  swallow  if 
food  is  put  into  his  mouth.  From  this  first  stage,  which  may  last 
many  days,  the  patient  may  recover  without  further  trouble,  or  he 
may  gradually  sink  and  die  without  reaction;  or  the  first  stage  may 
last  a  few  moments  only,  the  patient  having  passed  into  the  second 
stage  before  the  surgeon  sees  him.  The  disappearance  of  the  first 
stage,  whether  by  passing  into  the  second  or  by  direct  recovery, 
commonly  is  marked  by  vomiting,  (2)  In  the  second  stage  the  patient 
is  no  longer  unconscious,  though  much  indisposed  to  speak  or  pay 
attention  to  surrounding  objects.  If  roused  by  a  question,  he  will 
answer,  but  peevishly  or  angrily,  turning  away  as  if  displeased  at 
the  interruption.  His  posture  is  peculiar:  he  lies  habitually  on  his 
side,  curled  up,  with  all  his  joints  more  or  less  flexed,  and  if  a  limb 
is  touched  he  draws  it  away  with  an  air  of  annoyance.  The  eyelids 
are  kept  firmly  closed.    The  pulse,  at  first  slow  and  weak,  gradually 

'  This  description  is  copied,  almost  verbatim,  from  the  Principles  and  Practice 
of  Surgery-  of  John  Ashhurst,  Jr. 


COMPRESSION   OF   THE  HRAIN  ')71 

becomes  more  frequent  and  stronger;  the  l)reatliinfi;  is  easier,  and  the 
surface  regains  its  natural  warmtii  and  color.  This  staj^e  gradually 
subsides,  after  se\eral  hours  or  days,  and  as  the  patient  rej^ains 
ability  and  willingness  to  communicate  with  those  around  him, 
he  complains  almost  invariably  of  severe  headache.  If  the  cerebral 
lesions  have  been  marked,  they  may  leave  the  j)atient  with  his  mental 
faculties  permanently  impaired;  usually,  however,  in  such  an  event, 
the  earlier  symptoms  will  have  been  those  of  compression  of  the 
brain  rather  than  those  recognized  as  due  to  concussion. 

Treatment. — The  patient  should  l)e  laid  horizontal,  with  the  head 
slightly  elevated,  in  a  darkened  room;  and  throughout  his  illness 
he  should  be  protected  from  all  noise.  During  the  first  stage,  stimu- 
lation for  shock  may  be  necessary.  So  soon  as  shock  is  recovered 
from,  the  bowels  should  be  evacuated,  the  urine  drawn  if  necessary; 
and  moderate  amounts  of  liquid  nourishment  should  be  administered. 
During  the  second  stage,  cold  should  be  applied  to  the  head,  while 
restoration  of  cerebration  may  be  hastened  by  the  administration 
of  calomel,  one-sixth  of  a  grain  every  four  hours,  for  its  "anticipatory 
antiplastic  effect"  (p.  561);  and  this  may  be  continued  for  many 
days,  or  until  the  patient  is  clear  in  his  head.  Should  restlessness 
or  delirium  supervene,  it  is  well  to  administer,  with  each  dose  of 
calomel,  two  or  three  grains  of  Dover's  powder.  The  use  of  the  mind, 
in  conversation,  reading,  etc.,  should  be  resumed  very  gradually, 
and  convalescence  should  be  prolonged,  the  patient  living  by  rule 
for  many  months  after  apparent  recovery,  and  remaining  under 
surgical  observation  until  by  the  lapse  of  time  the  absence  of  com- 
plications from  unrecognized  cerebral  lesions  is  assured. 

Compression  of  the  Brain. — As  already  stated,  the  brain  is  an 
incompressible  structure;  its  bulk  can  be  reduced  only  by  loss  of 
its  fluid  constituents;  if  compressed  in  one  direction  it  must  expand 
in  another.  Experimental  compression  of  the  brain  produces  first 
a  stasis  in  the  smaller  venous  channels;  the  longitudinal  sinus  col- 
lapses; the  blood  cannot  escape  from  the  skull.  If  pressure  increases 
the  arterioles  may  be  affected.  Normally  changes  in  intracranial 
vascular  pressure  are  compensated  for  by  the  ebb  and  flow  of  the 
cerebrospinal  fluid.  This  drains  away  into  the  veins,  and  these 
in  turn  empty  mostly  into  the  longitudinal  sinus  and  certain  emissary 
veins  through  the  diploe.  Increase  in  vascular  pressure  from  the  arte- 
rial side  is  easily  and  rapidly  compensated  for  by  venous  absorption 
of  cerebrospinal  fluid;  and  obstruction  to  the  venous  outflow  (often 
seen  in  cases  of  cervical  or  thoracic  neoplasms)  does  not  prove  inju- 
rious so  long  as  the  collateral  diploic  veins  are  open,  or  so  long  as  the 
cerebrospinal  fluid  can  pass  into  the  spinal  canal  and  escape  into  the 
venous  circulation  by  that  channel.  But  if  the  pressure  on  the  venous 
side  becomes  so  great  as  to  dam  the  blood  back  into  the  capillaries, 
these  side  escapes  become  blocked,  the  brain  may  be  forced  dowm 
until  the  medulla  chokes  off  the  outlet  for  cerebrospinal  fluid  through 
the   foramen   magnum,    and    symptoms  of    "compression"    appear. 


572  SURGERY  OF   THE  HEAD 

It  was  shown  experimentally  by  Althann,  in  1871,  and  since  his 
time  by  numerous  other  investigators,  that  "the  effect  of  space 
diminution  in  the  skull  was  identical  with  that  of  any  other  process 
which  hindered  cranial  circulation"  (Archibald,  1908);  so  that,  as 
pointed  out  l)y  von  Bergmann  (1880),  the  symptoms  of  "compression" 
are  due  not  to  actual  compression  of  nerve  elements,  but  to  cerebral 
anemia. 

The  maintenance  of  life  depends  on  the  functioning  of  the  chief 
medullary  centres,  ^'as()motor,  vagus,  and  respiratory;  and  it  is  to 
interference  with  the  circulation  of  these  centres  that  the  most  strik- 
ing symptoms  of  cerebral  compression  are  due.  Localized  compression 
produces  the  so-called  focal  symptoms,  i.  c.,  paralysis;  while  general- 
ized ■  compression,  which  may  develop  independently  of,  or  may 
succeed,  local  compression,  is  particularly  characterized  by  bulbar 
symptoms:  interference  with  the  centres  already  named;  but  in 
generalized  compression  there  also  usually  is  unconsciousness,  from 
cortical  compression. 

So  soon  as  anemia  affects  the  medulla,  the  vasomotor  centre  is 
stimulated,  blood-pressure  is  raised  higher  than  intracranial  (extra- 
vascular)  pressure,  blood  again  reaches  the  medulla,  and  life  is  pro- 
longed, at  least  temporarily  (von  Schulten,  1885).  But  the  stimulus 
of  anemia  then  being  removed,  blood-pressure  sinks  somewhat,  as 
intracranial  pressure  continues  to  increase,  and  anemia  of  the  medulla 
again  occurs;  whence  renewed  stimulation  of  the  vasomotor  centre, 
a  further  rise  in  blood  pressure,  and  again  a  temporary  relief  of  the 
medullary  anemia.  Cushing  (1902,  1^0-3)  has  been  able  to  follow 
these  successive  periods  of  anemia  and  return  of  circulation  by  obser- 
vation of  the  cerebral  cortex  of  monkeys  through  a  trephine  opening; 
and  his  experiments  justify  the  conclusion  that  similar  changes  occur 
in  the  medulla. 

This  alternate  stimulation  and  depression  of  the  medullary  centres 
explains  the  more  or  less  periodic  phases  observed  in  the  blood- 
pressure  and  respiration  curves  obtained  from  such  patients.  They 
are  known  as  Traube-Hering  waves.  The  respiratory  phases  closely 
resemble  the  Cheyne-Stokes  type,  the  stage  of  apnea  occurring  when 
the  respiratory  centre  is  deprived  of  blood,  and  the  hyperpnea  develop- 
ing when  circulation  is  restored  by  increase  in  blood-pressure.  This 
"life  and  death  struggle,"  as  von  Schulten  termed  it,  may  continue 
until  blood-pressure  reaches  enormous  heights;  Cushing  raised  it 
experimentally  to  290  mm.  Hg.;  but  unless  intracranial  pressure  is 
relieved,  the  medullary  centres  in  time  will  cease  to  react,  and 
sudden  fall  of  blood-pressure  will  occur,  followed  by  death.  "Death 
probably  always  occurs  from  primary  failure  of  the  vasomotor  centre, 
rather  than  from  that  of  the  respiratory,  as  has  been  asserted  by 
some.  The  vasomotor  centre  holds  the  key  to  the  position.  Its 
defeat  involves  that  of  the  respiratory  and  vagus  centres;  and  with 
their  defeat  the  whole  armv  is  devoted  to  slaughter."  (Archibald, 
1908.) 


COMPRESSION  OF   THE   JiliAIN  nl'.^ 

Causes. — Anything;  which  increases  iiitracrania]  pressure  may 
cause  symptoms  of  compression  of  the  brain.  This  inchides:  (1) 
Foreign  bodies  driv'cn  against  or  into  the  brain  (bone  fragments, 
l)ullets,  etc.);  (2)  hemorrhage,  subcranial,  sub(hiral,  or  intracerebral; 
(o)  pro(hiets  of  iiiiiammatiou  (serous  cfrusion,  lymph,  pus);  (4) 
tumors  of  tlie  brain;  (o)  accpiired  internal  hydrocephahis,  etc. 

Symptoms. — ^'ery  sK)wly  induced  compression  ma\'  not  produce 
symptoms  for  a  h)ng  period;  and  even  in  cases  of  rapid  compression 
tliere  often  is' a  ".s7ar/r  of  conipni.'iation''  from  rise  in  blood-pressure, 
during  which  no  symptoms  may  be  observed.  During  the  sfaf/r  of 
manifest  comprcfision  two  periods  may  be  recognized:  (1)  Karly 
sipnpioms:  There  is  irritation  of  the  cortical  and  medullary  centres, 
due  to  venous  stagnation;  slight  quickening  of  respiration,  and  rise 
in  blood-pressure;  headache,  dizziness,  restlessness,  roaring  in  the 
ears,  disturbed  sleep;  moaning  and  groaning;  and  at  times  delirium. 
Sometimes  circulatory  changes  in  the  fundus  oculi  can  be  detected, 
but  these  disappear  in  a  few  hours.  (2)  Late  symptoms:  The  gradual 
increase  in  the  compressing  force  finally  overcomes  the  blood-pressure, 
and  cerebral  anemia  results.  This  stimulates  the  vasomotor  centre 
which  raises  blood-pressure  yet  higher  by  causing  peripheral  capillary 
constriction,  especially  in  the  splanchnic  area.  The  patient  lies 
somnolent,  stuporous,  even  comatose;  with  slow,  full,  bounding 
pulse;  there  is  labored  respiration,  which  in  the  last  stages  approaches 
the  Cheyne-Stokes  type;  the  cheeks  are  passively  puflFed  out  at  each 
expiration  ("smoking  his  pipe,"  the  French  call  it);  the  pupils  react 
sluggishly  or  not  at  all.  The  more  dilated  pupil  usually  is  on  the  side 
of  greatest  compression.  Sometimes  the  patient  can  be  partially 
roused  from  his  coma  by  pressure  on  the  supra-orbital  nerve;  then 
slight  convulsive  movements  of  the  extremities  may  occur,  and  hemi- 
plegia, or  localized  paralysis  may  become  evident.  Irregularity  of 
the  respiration  is  one  of  the  earliest  and  surest  signs  of  approaching 
exhaustion  of  the  medullary  centres;  and  unless  blood-pressure  can 
be  measured  periodically  by  the  manometer,  respiration  is  a  more 
reliable  guide  as  to  prognosis  than  the  quality  of  the  pulse;  for  the 
"vagus  pulse,"  slow%  regular,  and  strong,  continues  practically 
unchanged  until  very  near  the  fatal  ending. 

Diagnosis, — If  the  early  symptoms  of  the  stage  of  manifest  com- 
pression were  borne  in  mind,  the  condition  often  could  be  diagnosed 
and  measures  for  relief  instituted,  before  the  later  stage,  complicated 
by  unconsciousness,  is  reached.  When  an  unconscious  patient  is 
examined,  the  existence  of  an  adequate  cause  for  cerebral  compres- 
sion always  should  be  excluded  before  dismissing  this  as  the  cause 
of  the  symptoms.  ]\Iany  a  patient  suffering  from  cerebral  compression 
has  been  sent  awa}'  from  accident  wards  as  "drunk,"  when  a  very 
little  time  spent  in  examination  would  have  detected  focal  symptoms 
(pupillary,  facial,  or  lingual  paralysis;  monoplegia,  hemiplegia,  etc.); 
while  bulbar  symptoms  probably  could  have  been  discovered  if  they 
had  been  specifically  looked  for.     In  any  case  of  doubt,  keep  the 


574  SURGERY  OF   THE  HEAD 

patient  under  observation;  if  the  cause  of  symptoms  is  compression, 
this  soon  will  become  evident. 

Prognosis.^ — This  depends  very  largely  upon  the  cause  of  the  com- 
pression, and  the  time  at  which  treatment  is  instituted.  In  many 
cases  of  brain  tumor,  for  instance,  it  may  be  impossible  to  remove 
the  cause  of  compression,  so  that  cure  is  out  of  the  question;  but 
symptoms  may  be  relieved  and  life  prolonged  by  removing  the  counter- 
pressure  caused  by  the  skull.  But  even  in  cases  where  the  cause  of 
compression  can  be  removed,  treatment  may  not  be  instituted  until 
the  last  stages  of  compression,  and  the  medullary  centres  may  not 
recover;  or  even  though  they  recover,  the  focal  compression  may  have 
done  so  much  damage  to  the  cerebrum  as  to  impair  the  patient's 
mental  or  physical  ability  throughout  life. 

Treatment. — From  what  has  been  said  above  it  is  very  evident 
that  the  two  main  indications  are  to  maintain  blood-pressure  at  a 
higher  point  than  intracranial  (extravascular)  pressure,  and  to  relieve 
the  compression  by  surgical  means.  The  full,  bounding  pulse,  the 
singing  in  the  ears,  etc.,  of  the  early  stages,  do  not  by  any  means 
indicate  that  the  patient  should  be  bled,  or  that  aconite  should  be 
administered;  they  are  an  index  of  his  compensatory  powers  and 
all  that  will  save  his  life  is  to  keep  his  blood-pressure  high,  and  to 
relieve  the  intracranial  pressure  as  quickly  as  possible.  Theoretically 
the  latter  point  may  be  gained  by  lumbar  puncture  of  the  subdural 
space  of  the  cord;  but  draining  away  cerebrospinal  fluid,  by  removing 
the  brain's  support  from  below,  may  serve  only  to  allow  the  super- 
incumbent pressure  to  force  the  medulla  down  into  the  foramen 
magnum,  thus  strangulating  it  and  causing  instant  death.  The  most 
imperative  indication  is  to  "decompress"  the  brain  by  removing 
some  of  the  overlying  cranium,  on  one  or  both  sides.  This  may  be 
done  by  the  trephine,  the  opening  being  enlarged  by  rongeur  forceps, 
or  a  bone-flap  may  be  raised  (p.  586).  At  the  same  time  that  decom- 
pression is  done,  the  cause  of  compression,  whenever  possible,  should 
be  removed.  The  site  of  the  cranial  opening  depends  on  the  cause 
of  compression  and  on  the  existence  of  focal  symptoms;  when  not 
contraindicated  the  subtemporal  operation  of  Gushing  (p.  590)  is 
very  satisfactory. 

In  the  most  advanced  stages  of  cerebral  compression  emergency 
measures  are  necessary  to  raise  the  blood-pressure  until  operation 
can  be  undertaken;  these  are  such  methods  as  artificial  respiration, 
lowering  the  patient's  head,  bandaging  his  extremities,  compression 
of  the  abdomen,  and  the  administration  of  strychnin,  adrenalin,  etc. 
After  decompression  it  should  be  remembered  that  the  stimulating 
effect  of  recurring  anemia  upon  the  vasomotor  centre  is  lost;  and 
if  this  centre  shows  signs  of  exhaustion,  it  must  be  stimulated  by 
str.ychnin,  or  repeated  doses  of  adrenalin. 

Subcranial  or  Extradural  Hemorrhage  may  be  due  to  bleeding 
from  the  diploe  or  cranial  sinuses,  in  cases  of  fracture  of  the  skull, 
but  in  the  vast  majority  of  cases  it  is  due  to  rupture  of  the  middle 


COMI'lil'JSSION   OF    TIll'J   lih'AIN 


i^ti^ 


incniiiiijciil  artery.  Middle  iiirn'ni(i<'(d  IwiiiorrlKuje  may  occur  with  or 
without  fracture  of  the  skull,  aud  upou  the  side  of  iujury  or  ou  the 
opi)osite  side  (from  "contre-coup").  The  anterior  l)raneh  of  the 
artery  is  most  often  ruptureci,  usually  near  the  pterion,  where  it 
passes  throujjjh  a  bony  f^roove  or  canal;  but  it  may  be  torn  off  at  its 
exit  from  the  foramen  spinosum  (by 
concussion,  or  by  a  burstinjj;  frac- 
ture), or  lacerated  by  bone  fragments 
at  other  i)arts  of  its  course.  The 
bleeding  which  results  slowly  sepa- 
rates the  dura  from  the  cranium,  and 
the  resulting  clot  may  spread  over 
an  entire  hemisphere  (Fig.  ()2()). 

Diagnosis. — The  usual  history  is 
that  after  an  injury  to  the  head 
the  patient  experiences  momentary 
symptoms  of  concussion,  then  re- 
covers more  or  less  completely ;  but 
some  hours  or  even  days  later  signs 
of  compression  appear,  sometimes 
gradually,  sometimes  with  alarming 
suddenness.  What  is  particularly 
characteristic  is  the  so-called  "free 
interval,"  between  the  injury, 
when  rupture  occurs,  and  the 
time  when  the  accumulating  clot 
brings  on  symptoms  of  compres- 
sion. 

Treatment. — The  treatment  consists  in  exposing  the  main  trunk 
or  anterior  branch  of  the  artery,  removing  the  clot,  tracing  the  bleed- 
ing to  its  source,  and  ligating  the  artery  by  passing  a  fine  suture 
around  it  by  means  of  a  round-pointed  needle.  T.  R.  Neilson  (11)03) 
plugged  the  foramen  spinosum  wdth  a  match-stick.  If  the  hemorrhage 
does  not  come  from  the  anterior  branch,  the  posterior  should  be 
exposed.  If  all  focal  signs  are  absent,  and  no  cause  for  compression 
is  found  on  the  side  of  the  skull  first  opened,  it  is  justifiable  to  open 
the  other  side,  as  rupture  may  occur  from  counter-stroke. 

Intradural  Hemorrhage. — Bleeding  into  the  meshes  of  the  pia- 
arachnoid,  which  is  much  more  frequent  than  the  extradural  form, 
almost  invariably  is  of  traumatic  origin,  venous  in  character,  and 
complicated  by  extensive  cranial  and  cerebral  injury  (Fig.  021). 
Usually  the  blood  is  widely  diffused,  and  the  fluid  removed  by  lumbar 
puncture  may  be  blood-tinged.  The  symj)to7ns  are  those  of  cerebral 
compression;  "it  is  safe  to  say,"  writes  Gushing,  "that  in  anj^  serious 
cranial  injury  in  which  unconsciousness  has  been  present  from  the 
first,  subdural  bleeding  is  taking  place,  either  from  the  fracture 
itself  or  from  some  laceration  of  the  brain."  Treatment  consists  in 
decompression  if  symptoms  of  compression  continue  for  more  than  a 


Fig.  020.  —  Subcranial  hemorrhage 
from  rupture  of  the  posterior  branch  of 
the  middle  meningeal  artery.  No  frac- 
ture of  the  cranium.  Man,  aged  fifty- 
one  years,  was  found  lying  on  the  street, 
unconscious.  Taken  to  police  station. 
Operation  about  forty  hours  after  in- 
jury. Blood-pressure  fell  from  170 
mm.  before  operation  to  110  mm.  a  few 
hours  later.  Recovery.  Episcopal  Hos- 
pital. 


576  SURGERY  OF   THE  HEAD 

few  hours  or  are  well  marked  at  first.  Seldom  is  it  possible  to  find 
any  distinct  bleeding  point,  but  exposure  to  the  air,  or  gentle  irriga- 
tion with  very  hot  saline,  may  be  sufficient  to  arrest  the  hemorrhage. 
Drainage  is  provided  by  strips  of  rubber  tissue.  The  operation, 
unless  another  opening  is  indicated  by  focal  symptoms,  should  be 
by  Cushing's  subtemporal  route  (p.  590)  which  gives  ready  access 
to  the  base  of  the  brain  whence  the  bleeding  usually  arises.  As 
already  mentioned  (p.  566),  Nassau  tampons  the  subdural  tissues 
for  four  days,  then  replaces  the  dural  flap. 


Fig.  621. — Intradural  hemorrhage.  A  boy  of  five  years  had  a  large  flap  of  scalp  torn 
loose.  Parietal  bone  bent  inward,  but  no  fracture.  Operation  three  hours  later  (for 
continued  unconsciousness  and  left  hemiplegia)  showed  extensive  intradural  hemor- 
rhage, the  brain  being  4  cm.  distant  from  the  dura.  After  removal  of  compression  respira- 
tion improved,  but  death  occurred  in  a  few  hours.    Episcopal  Hospital. 

Intracranial  Hemorrhages  in  the  Newborn. — These  occur  usually 
from  a  rupture  of  a  vein  in  the  pia-arachnoid,  near  the  longitudinal 
sinus,  as  the  result  of  trauma  during  birth.  The  diagnosis  is  not 
always  easy,  at  least  until  signs  of  compression  of  the  brain  appear; 
lumbar  puncture  may  show  bloody  cerebrospinal  fluid;  and  cerebral 
irritability  and  irregularity  of  respiration  are  suggestive.  The  prog- 
nosis is  bad;  nearly  80  per  cent,  die  from  cerebral  compression  within 
a  few  days;  while  of  those  that  recover  most  are  mentally  deficient 
or  afflicted  with  spastic  paralysis  (p.  530),  athetosis,  nystagmus, 
etc.  Treatment:  Operative  relief,  proposed  by  Keen  in  1901,  was 
first  employed  in  1904  by  Cushing,  who  has  reported  (1908)  nine 
operations,  with  four  recoveries.  A  large  osteoplastic  flap,  which 
can  be  cut  out  with  strong  scissors,  is  raised,  the  dura  is  opened,  the 
clots  removed  by  gentle  irrigation,  and  the  wound  closed  without 
drainage. 

Intracerebral  Hemorrhage  occurs  chiefly  as  the  result  of  vascular 
disease  (ordinary  "apoplexy"),  or  from  degenerative  changes  in 
brain  tumors.  Wounds  are  occasionally  causes  of  localized  cortical 
hemorrhage.  The  suggestion  by  Leonard  Hill  (1896)  that  surgery 
by  effecting  decompression,  or  even  by  evacuation  of  the  clot,  might 
be  of  use  in  these  cases,  was  acted  upon  with  success  by  Borsuk  and 


SIMS  riiiioMiiosis  :ui 

Wizel  (I.S97)  ill  ;i  tr;iiiniatic  case,  ("iisliiiij;  (1!)()S)  lias  ((pcratcd  on 
four  cases  oF  spontaneous  lieniorrha^c,  one  operation  (suhtcuiporai 
decompression  and  e\acuation  ot"  tlie  clot)  heinj^  successful.  I'lider 
expectant  treatment  the  mortality  is  nearl.x  00  per  cent.,  in  these 
cases  of  acute  severe  apoplexy,  in  which  alone  is  operation  to  be 
considered. 

Sinus  Thrombosis. This  arises,  in  the  vast  majority  of  cases,  by 
extension  of  .septic  iuHammation  from  the  air  sinuses  of  the  skull, 
especially  tlie  mastoid  cells.  Pyoffcnic  inflammation  of  the  scalp  or 
erysipelas  are  rare  cau.ses,  the  infection  spreading  along  the  diploic 
emissary  veins.  The  (licifino.sis  depends  on  reco<;nizinff  a  focus  from 
which  sei)tic  inflannnation  may  be  derived,  on  local  sij^ns  such  as 
edema  of  the  overlyinj;  scalp,  and  distention  of  its  veins,  together 
with  evidences  of  constitutional  sepsis,  and  perhaps  cerebral  com- 
pression. The  longitudinal  sinns  may  be  thrombosed  from  frontal, 
ethmoidal,  or  si)hen(Mdal  sinusitis,  or  rarely  from  erysipelas  of  the 
scalp,  etc.  Thrombosis  of  the  cavernovs  sinus,  which  is  very  rare, 
may  arise  from  extension  of  inflammation  along  the  facial  and  angular 
veins  (carbuncle  of  upper  lip,  etc.),  or  along  the  petrosal  sinuses 
(from  the  sigmoid  sinus),  and  is  particularly  characterized  by  the 
resulting  exophthalmos. 

The  lateral  sinus,  especially  its  sigmoid  portion,  is  that  which  is 
involved  in  by  far  the  largest  number  of  cases,  and  almost  always 
as  the  result  of  middle-ear  disease,  the  infection  coming  along  the 
emissary  veins  or  directly  invading  the  sinus  wall  after  destruction 
of  the  intervening  bone.  The  symptoms  are  those  of  the  preexisting 
disease  (mastoiditis),  of  sepsis  (repeated  chills,  sweating,  hectic 
temperature),  and  cerebral  irritation  or  compression  (rare);  but 
such  symptoms  often  do  not  appear  until  the  sinus  thrombosis  has 
been  in  existence  for  some  days,  and  may  indicate  a  softening  of  the 
clot  and  dissemination  of  emboli.  Naturally  the  lungs  are  most 
often  attacked  in  this  way.  Thrombosis  is  prone  to  extend  to  the 
internal  jugular  vein,  and  often  this  can  be  felt  as  a  tender  cord  in  the 
neck.  The  head  may  be  tilted  to  the  affected  side.  In  meningitis, 
which  is  much  commoner  in  infants  than  adults  as  a  result  of  middle- 
ear  disease,  cerebral  symptoms  (vertigo,  vomiting,  hebetude,  delirium) 
are  more  marked,  there  is  retraction  of  the  neck  and  paralysis  of  the 
ocular  muscles,  with  choked  disk;  fever  is  higher  and  more  regular; 
Kernig's  sign  is  present;  and  lumbar  puncture  shows  turbid  cerebro- 
spinal fluid,  from  which  organisms  may  be  recovered.  In  brain 
ab.scess  cerebral  symptoms,  without  those  of  meningitis,  predominate; 
temperature  is  subnormal;  there  is  evidence  of  cerebral  compression; 
and  emaciation  is  rapid.  In  neither  meningitis  nor  in  uncomplicated 
cases  of  brain  abscess  is  there  thrombosis  of  the  internal  jugular  vein. 

Treatment. — The  first  step  is  to  clear  out  the  mastoid,  and  this 
merely  preliminary  measure  should  not  be  done  with  too  great  delib- 
eration (see  Chapter  XIX).  The  shell  of  bone  which  overlies  the 
sigmoid  sinus  is  then  removed  by  gouge  or  burr,  and  the  sinus  well 
37 


578  SURGERY  OF   THE  HEAD 

exposed;  plenty  of  room  should  be  gained  by  use  of  the  rongeur.  The 
sinus  is  next  incised:  if  bleeding  occurs  the  sinus  is  compressed  first 
on  the  torcular  side;  and,  if  it  continues,  also  on  the  jugular  side  of 
the  incision.  Persistence  in  bleeding,  when  pressure  is  made  at  both 
these  points,  indicates  a  return  flow  from  the  mastoid  emissary  or 
superior  petrosal  sinus.  These  should  be  separately  tested.  If  the 
petrosal  is  not  thrombosed  it  is  probable  that  the  entire  system  is 
healthy.  7/  no  bleeding  occurs  when  the  sinus  is  opened,  it  should 
be  slit  up  toward  the  torcula  until  a  return  flow  is  obtained;  this  is 
controlled  by  packing;  the  clot  is  then  removed  as  far  as  the  original 
incision,  and,  after  temporary  pressure  has  been  made  on  both  jugulars 
in  the  neck,  a  similar  procedure  is  carried  out  at  the  bulbar  end  of  the 
sinus.  If  no  return  flow  can  be  obtained  from  this  end  of  the  sinus, 
it  is  a  sign  that  the  thrombus  extends  into  the  jugular,  and  resection 
of  this  vein  should  be  done.  It  is  to  be  performed  as  a  primary  oper- 
ation, before  exposing  the  sinus,  when  a  diagnosis  of  jugular  thrombosis 
is  made  in  advance.  Resection  of  the  Internal  Jugular  Vein:  The 
vein  is  exposed  and  doubly  ligated  low  in  the  neck;  it  is  divided 
between  these  ligatures  and  dissected  upward,  clamping  and  tying 
each  branch  encountered.  Thrombosed  branches  should  be  excised. 
When  the  vein  has  been  traced  up  as  far  as  possible,  it  is  ligated  and 
cut  across.  The  neck  wound  is  tamponed  with  gauze  and  not  closely 
sutured.  If  the  jugular  vein  is  too  densely  adherent  to  be  removed 
safely,  it  should  be  slit  open,  and  the  wound  packed  with  gauze. 
The  general  mortality  of  thrombosis  of  the  lateral  sinus  is  about  25 
per  cent. 

Meningitis. — External  Pachymeningitis,  usuall.y  purulent  and  local- 
ized (subcranial  abscess),  affects  the  external  layer  of  the  dura,  and 
may  result  from  osteomyelitis  of  the  cranium  (p.  566)  with  or 
without  fracture  of  the  skull,  or  from  neighboring  sinus  thrombosis. 
Treatment  consists  in  removal  of  the  overlying  bone,  with  drainage. 

Internal  Pachymeningitis  is  a  rare  disease,  of  subacute  or  chronic 
character,  in  which  membranous  lymph,  easily  detachable,  is  deposited 
on  the  inner  layer  of  the  dura.  It  is  microbic  in  origin,  occurs  some- 
times in  general  infections  (typhoid  fever,  pneumonia),  and  some- 
times is  hemorrhagic  in  type.  The  symptoms  are  not  very  character- 
istic, being  those  of  slowly  increasing  cerebral  irritation  or  compres- 
sion; and  the  diagnosis  is  difficult.  Treatment:  operation,  comprising 
removal  of  the  false  membrane  or  hemorrhagic  exudate,  offers  the 
only  hope  of  cure  or  prevention  of  insanity  (Munro,  1902). 

Leptomeningitis. — Inflammation  affecting  the  pia-arachnoid  may 
be  due  to  a  number  of  bacteria;  the  form  known  as  epidemic  cerebro- 
spinal meningitis,  caused  by  the  Diplococcus  intracellularis,  is  a 
specific  contagious  disease,  usually  coming  under  the  physician's 
care.  Early  use  of  Flexner's  serum  (1906)  is  most  important.  As 
the  ultimate  cause  of  death  is  purely  mechanical,  being  due  to  cerebral 
compression  from  acute  internal  hydrocephalus  (p.  554),  surgical 
treatment  may  be   advisable  when  purely   medical  measures  have 


BRAIN  ABSCESS  579 

failed.  Lumbar  puucturo,  used  for  diagnosis,  is  of  no  therapeutic 
value  wlien  liytlroceplialus  supervenes;  the  only  remedy  is  single  or 
rej)eated  puncture  of  the  ventricles. 

Leptomeningitis  also  may  be  caused  by  ordinary  pyogenic  cocci, 
pneumococcus,  B.  tuberculosis,  etc.  P^specially  in  tiibrrciiloKS  inenin- 
gitis,  which  is  so  uniformly  fatal  under  medical  treatment,  it  seems 
as  if  almost  any  surgical  risk  were  justifiable.  Lumbar  puncture 
will  relieve  the  intracranial  tension,  due  to  accumulation  of  sero- 
purulent  exudate,  so  long  as  the  medulla  is  not  driven  down  like  a 
cork  into  the  foramen  magnum,  or  so  long  as  the  foramina  in  the 
roof  of  the  fourth  ventricle  are  patulous  (p.  554).  But  when  acute 
internal  hydrocephalus  develops,  the  only  hope  of  relief  lies  in 
tapping  the  ventricles  (p.  555)  or  their  permanent  drainage  into  the 
subdural  space  (p.  55(i). 

Serous  or  Amicrobic  Meningitis  is  a  form  of  the  aflection  in  which 
clear,  sterile  serous  fluid  collects  in  the  intradural  spaces  (Eichhorst, 
1887).  Some  cases  are  traumatic  in  origin,  but  most  are  regarded 
as  due  to  bacterial  infection  localized  elsewhere  in  the  body,  thus 
being  analogous,  as  pointed  out  by  Archibald  (1908),  to  the  sterile 
serous  effusion  of  pleurisy  secondary  to  subphrenic  abscess.  Some- 
times this  affection  complicates  sinus  thrombosis  or  mastoiditis. 

Diagnosi,s. — The  diagnosis  is  difficult,  the  serous  character  of  the 
effusion  being  discovered  first  at  operation  undertaken  to  relieve 
pressure  symptoms  thought  to  be  due  to  subcranial  or  intradural 
suppuration,  or  to  brain  abscess. 

Treatment. — In  traumatic  cases  lumbar  puncture  may  suffice  to 
evacuate  the  fluid;  in  others  craniotomy  should  be  done.  If  serous 
meningitis  is  found,  undue  persistence  should  not  be  exercised  in 
searching  for  a  brain  abscess  which  may  not  exist. 

Syphilis  of  the  Leptomeninges. — Practically  all  the  intracranial 
lesions  of  syphilis  arise  in  the  meninges  and  involve  the  brain  only 
secondarily,  by  pressure.  They  are  found  most  often  in  the  arachnoid 
tissues,  especially  in  the  frontal  region  and  at  the  base.  The  diagnosis 
from  cerebral  tumors  is  not  easy,  but  the  treatment  is  much  the 
same  (p.  585). 

Encephalitis  or  Cerebritis,  except  as  it  complicates  traumatic 
lesions,  concerns  surgeons  little,  unless  in  localized  form  (Brain 
Abscess).  There  is  supposed  to  be  an  epidemic  form,  analogous  to 
acute  anterior  poliomyelitis,  of  which,  probably,  more  will  soon  be 
heard. 

Brain  Abscess. — This  is  due  in  about  equal  proportions  to  tramna, 
especially  penetrating  and  punctured  wounds,  and  to  supimrative 
disease  of  the  mastoid  cells,  middle  ear,  or  other  air  sinuses  of  the 
cranium.  It  occurs  also  in  pyemia,  but  very  much  less  frequently. 
The  site  of  the  abscess  in  the  brain  depends  largely  on  the  focus  of 
infection.  Frontal  abscess  results  from  disease  of  the  frontal  sinuses, 
ethmoid  and  sphenoid  cells,  cavernous  sinus,  thrombosis,  etc.  Middle- 
ear  disease  is  the  chief  cause  of  abscess  in  the  temporo-sphenoidal 


5S(1 


SURGERY  OF   THE   HEM) 


lobe;  while  cerebellar  abscess  usually  is  secondary  to  mastoid  disease 
or  lateral  sinus  thrombosis.  The  causative  condition  frequently 
has  been  in  existence  for  months  or  even  years,  before  brain  abscess 
develops.  The  cerebrum  is  affected  more  than  twice  as  often  as  the 
cerebellum.  The  abscess  almost  always  is  in  the  subcortical  area 
of  the  brain,  and  seldom  has  any  macroscopical  connection  with  the 


Fig.  622.— Cerebral  abscess  from  mid- 
dle-ear disease;  initial  stage:  headache, 
nausea,  chilliness,  and  fever.  (G. 
Laurens.) 


Fig.  62.3. — Cerebral  abscess  from 
middle-ear  disease;  manifest  stage:  per- 
sistent headache,  mental  hebetude,  and 
other  symptoms  of  compression.     (G. 

Laurens.) 


source  of  infection,  having  arisen  from  embolism  (rare),  or  by  pro- 
gressive thrombosis  of  minute  venous  channels.  Usually,  if  not 
invariably,  however,  there  exi.sts  a  microscopic  connection  between 
the  source  of  infection  in  the  cranial  bones  and  the  abscess  cavity; 
the  abscess  has  been  compared  to  a  mushroom,  growing  by  a  stalk 
from  the  neighboring  carious  bone. 


Fn;.  624. — Cerebellar  abscess  from  middle-ear  disease,  simulating  meningitis 
(retraction  of  the  head,  occipital  headache,  etc.).     (G.  Laurens.) 


Symptoms. — AYhen  the  abscess  follows  middle-ear  disease,  which 
is  its  most  frequent  single  cause,  and  may  be  taken  as  the  type,  it  is 
usual  for  there  to  have  been  some  recent  exacerbation  of  the  chronic 
symptoms.  The  course  of  a  typical  case  is  well  sketched  by  Cushing: 
after  the  exacerbation  of  the  old  symptoms,  arise  those  of  the  initial 
stage  of  brain  abscess  (headache,  nausea,  chilliness,  and  fever)  (Fig. 


BRAIN  TVMOR  oSl 

022);  these  may  subside,  hut  rarely  disappear  entirely,  for  a  period  iA 
a  week  or  ten  days  {latent  stage) ;  then,  with  more  or  less  sudden  cessa- 
tion of  diseharfje  from  the  ear,  symptoms  of  intracranial  sepsis  and 
pressure  become  evident  (i)ersistent  headache,  mental  hebetude,  vom- 
iting, slow  pulse,  subnormal  temperature,  and  leukocytosis  (manifest 
stagr)  (Fig.  (528).  I'sually  there  are  no  distinct  focal  symptoms,  other 
than  marked  tenderness  of  the  overlying  skull,  and  sometimes  facial 
])aralysis.  Raj)id  emaciation  is  a  very  significant  sign.  If  the  abscess 
is  in  the  cerebellum,  meningitis  may  be  simulated  (Fig.  (524).  The 
distinction  between  abscess  and  tumor  of  the  brain  seldom  is  difficult 

(p.  r)S:5). 

Treatment. — The  abscess  must  be  drained  as  early  as  possible. 
Do  not  delay  overnight  if  you  suspect  an  abscess.  Some  surgeons 
prefer  to  do  a  tympano-mastoid  exenteration  first,  and  then  wait  a 
few  da}s,  to  see  if  the  symptoms  suggestive  of  brain  abscess  will 
subside;  but  if  an  abscess  is  present,  any  delay  is  dangerous.  IMany 
operators  prefer  to  open  the  intact  cranium  (Macewen,  1893)  over 
the  supposed  site  of  abscess,  and  to  proceed  to  exenteration  of  the 
tympano-mastoid  only  after  evacuating  the  abscess.  For  abscess 
in  the  temporu-sphenoidal  lobe  trephine  at  a  point  one  inch  above  the 
supra-meatal  spine.  The  cerebellum  is  exposed  by  trephining  below 
the  lateral  sinus  and  posterior  to  its  sigmoid  portion.  ]Most  aurists 
think  it  safer  to  approach  the  brain  abscess  through  the  middle 
ear  or  mastoid,  because  by  this  avenue  one  is  most  certain  to  cross  the 
meninges  where  adhesions  exist,  and  can  follow  on  to  the  abscess 
along  its  "stalk."  ^Yhen  the  cortex  is  exposed,  in  either  case,  measures 
should  be  taken  to  prevent  contamination  of  the  meninges,  unless 
the  diseased  area  is  isolated  already  by  adhesions.  The  brain  is 
then  explored  by  a  grooved  director,  and  when  pus  is  found  the 
overlying  cortex  is  incised  on  the  director,  sufficiently  to  secure 
drainage.  This  is  difficult  to  maintain,  as  the  semifluid  brain  tends 
to  block  the  tube.  Should  damming  up  of  pus  be  suspected  the 
wound  must  be  reopened.  Even  in  the  hands  of  the  most  skilled 
and  expert  surgeons,  operation  for  brain  abscess  is  attended  by  a 
mortality  of  about  50  per  cent.;  but  as  all  patients  will  die,  and  quite 
as  soon,  if  no  operation  is  done,  this  should  not  deter  one  from  trying 
to  save  even  moribund  patients. 

Brain  Tumor. — Any  growth  within  the  cranium,  whether  a  true 
neoplasm  or  an  infectious  granuloma,  is  considered  clinically  a 
"brain  tumor,"  because  productive  of  the  same  general  signs.  Tuber- 
culoma is  the  most  frequent  growth  in  childhood;  these  tumors  occur 
with  special  frequency  in  the  cerebellum,  and  often  are  multiple. 
Syphiloma  is  more  common  in  adults,  being  usually  a  meningeal 
growth  which  compresses  the  brain  secondarily.  These  two  t}'pes 
of  growth  from  a  larger  class  of  brain  tumors  than  do  the  true  neo- 
plasms. Of  the  latter,  the  most  frequent  are  endothelioma  and  glioma. 
The  former  grows  from  the  meninges,  usually  is  encapsulated  and 
easily  enucleated  from  the  cup-shaped  depression  it  produces  in  the 


582  SURGERY  OF   THE  HEAD 

surface  of  the  brain;  the  glioma,  on  the  other  hand,  usually  is  an 
infiltrating  growth  of  the  subcortical  area,  and  is  with  difficulty 
distinguishable  macroscopically  from  normal  brain  tissue.  Sarcoma, 
which  is  less  usual,  grows  from  the  connective  tissue  of  the  meninges, 
frequently  invading  the  bone;  or  may  arise  in  the  cortex,  whence  it 
sometimes  can  be  shelled  out,  owing  to  peripheral  degenerative  changes. 
Often  it  is  multiple,  and  is  a  more  frequent  form  of  metastatic  growth 
than  carcinoma.  Fibroma  is  seldom  seen  except  in  the  cerebello- 
pontine angle.  Cysts  occur  in  the  brain;  some  are  of  parasitic  origin 
(echinococcus,  cysticercus),  others  are  the  result  of  hemorrhages  into 
the  brain  substance,  or  arise  as  degenerative  changes  in  a  glioma. 
The  latter  is  the  usual  cause  of  cerebellar  cysts. 

Symptoms. — Tumors  grow  in  the  brain  oftener  than  in  any  other 
part  of  the  body.  Hale  White  (1885)  estimated  that  a  tumor  is  found 
in  the  brain  in  one  among  every  59  autopsies.  They  may  exist  for 
years  and  cause  no  symptoms,  if  in  a  silent  region  or  if  of  very  slow 
growth.  They  occur  mostly  between  the  ages  of  fifteen  and  fifty.  In 
old  age  and  infancy  they  are  rare.  It  is  usual  to  discuss  the  symp- 
toms of  brain  tumor  under  two  headings,  general  symptoms,  and 
localizing  symptoms. 

General  Symptoms. — The  syndrome  of  brain  tumor  comprises  the 
three  cardinal  symptoms,  headache,  vomiting,  and  papilledema.  Headache 
at  first  is  intermittent,  but  when  constant,  and  especially  when  referred 
persistently  to  one  region,  which  is  tender  to  percussion  or  pressure, 
must  be  regarded  as  highly  significant;  probably  it  is  due,  as  pointed 
out  by  Gushing  (1908),  to  pressure  upon  or  distortion  of  the  falx 
or  tentorium,  as  the  brain  itself  is  insensitive.  The  vomiting,  perhaps 
due  to  irritation  of  the  pneumogastric  nerve,  is  projectile  in  character, 
may  occur  independently  of  meals,  and  be  unattended  by  nausea. 
Papilledema,  optic  neuritis,  or  choked  disk,  is  a  characteristic  change 
in  the  eye-grounds,  commonly  believed  to  be  due  to  damming  up  of 
the  cerebrospinal  fluid  in  the  sheath  of  the  optic  nerve,  as  the  result 
of  increased  intracranial  tension.  If  this  pressure  is  not  relieved, 
hemorrhages  may  occur  in  the  nerve  head  and  retina,  resulting  in 
permanent  blindness.  Usually  both  optic  nerves  are  affected,  but 
unequal  involvement  of  the  two  nerves  does  not  indicate  that  the 
compressing  lesion  is  on  the  side  where  papilledema  is  greatest, 
unless  only  one  nerve  is  appreciably  involved.  Papilledema  often 
is  more  marked  in  subtentorial  lesions  than  others.  The  importance 
of  examining  the  eye-grounds  in  all  suspected  cases  of  intracranial 
lesion  cannot  be  too  much  emphasized,  as  acuity  of  vision  may  persist 
even  when  papilledema  is  moderately  far  advanced.  On  the  other 
hand,  this  sign  may  be  entirely  absent  throughout  the  course  of  the 
disease.  Gushing  recently  has  called  attention  to  changes  in  the 
color  fields,  detected  by  expert  ophthalmological  examination,  as 
one  of  the  earliest  of  the  general  signs  of  brain  tumor.  No  bulbar 
symptoms,  such  as  occur  in  compression  of  the  brain  from  trauma, 
are  observed  in  cases  of  brain  tumor,  because  the  increase  in  pressure 


BhWI.S    TIMOR  583 

is  so  very  gradual.  Occasionally  a  hraiii  tumor,  previously  unsus- 
pected, makes  its  presence  known  first  by  the  occurrence  of  a  hemor- 
rhage into  the  tumor,  the  symptoms  resembling  those  of  ordinary 
apoplexy;  and  in  a  young  adult  such  an  occurrence  should  rouse  the 
suspicion  of  a  brain  tumor. 

Loralizinr/  Si/mptoms. — These  are  interpreted  through  anatomical 
knowledge  of  the  seat  of  the  cerebral  functions.  As  the  increase  in 
pressure  occurs  very  slowly,  it  is  the  rule  for  the  development  of  paralytic 
symptoms  to  be  delayed,  usually  being  preceded  by  irritative  symptoms 
(Jacksonian  epilepsy,  p.  oDO);  and  a  very  slowly  growing  tumor  in  a 
silent  region  of  the  brain  may  produce  no  localizing  symptoms  until 
by  encroachment  it  involves  the  nearest  physiologically  recognizable 
centre,  causing  "neighborhood"  as  distinguished  from  true  "focal" 
symptoms.  Thus  a  tumor  in  the  frontal  lobe  may  make  its  presence 
known  only  by  general  symptoms  (headache,  vomiting,  papilledema), 
until  so  large  as  to  interfere  with  the  motor  functions;  and  when 
paralysis  of  motion  at  last  occurs,  the  incautious  observer  may  jump 
to  the  conclusion  that  the  tumor  is  growing  in  the  motor  region; 
instead  of  recognizing  the  fact,  as  he  would  have  done  if  an  accurate 
history  of  the  progress  of  the  disease  had  been  obtained,  that  the 
growth  evidently  was  primary'  elsewhere,  and  had  compressed  the 
motor  region  only  secondarily. 

Diagnosis. — This  involves  not  only  the  determination  whether  a 
tumor  exi-sts  at  all,  but  also  the  recognition  of  the  kind  of  tumor 
present,  and  its  location. 

1.  Brain  tumor  may  be  closely  simulated  by  the  cerebral  symptoms 
of  chronic  nephritis;  the  urinary  changes  in  the  latter  condition  are 
the  chief  distinction,  but  as  a  brain  tumor  may  coexist,  the  patient 
should  be  watched  for  the  development  of  localizing  symptoms. 
Abscess  of  the  brain  usually  may  be  distinguished  from  brain  tumor 
by  the  history  of  trauma,  bone  disease,  etc.,  which  is  absent  in  the 
latter  affection;  as  well  as  by  the  more  acute  course  of  the  disease 
in  cases  of  brain  abscess.  Acquired  internal  hydrocephalus  (p.  554) 
is  to  be  distinguished  by  the  usual  bilateral  distribution  of  any  local- 
izing signs.  Sometimes  a  brain  tumor  may  be  detected  by  aid  of  a 
skiagraph. 

2.  llie  kind  of  tumor  is  very  difficult  and  usually  impossible  to 
determine.  The  existence  elsewhere  in  the  body  of  a  tuberculous 
process  naturally  would  suggest  a  tuberculoma  as  the  cause  of  the 
cranial  symptoms;  as  would  a  history  of  syphilis  or  evidence  of  past 
or  present  S3'philitic  lesions  the  existence  of  a  syphiloma.  The  tuber- 
culin tests  and  the  Wasserman  reaction  are  also  available.  The  use 
of  antisyphilitic  remedies,  as  a  method  of  exclusion,  though  quite 
habitual,  should  not  be  persisted  in  for  more  than  six  weeks  (Horsley, 
1890),  unless  relief  of  symptoms  is  secured  sooner;  because,  in  the 
first  place,  few  intracranial  syphilomas  are  permanently  influenced 
by  medication,  and,  secondly,  other  forms  of  tumor  ma}^  undergo 
temporary  regression  under  antisyphilitic  treatment,  only  to  cause 


584  SURGERY  OF   THE  HEAD 

renewed  symptoms  later.  Moreover,  it  is  quite  characteristic  of 
the  intracranial  lesions  of  syphilis  to  undergo  spontaneous  retro- 
gression and  recrudescence,  even  in  the  absence  of  treatment.  Lumbar 
puncture  may  aid  the  diagnosis  by  showing  the  constant  lymphocy- 
tosis so  characteristic  of  syphilis,  or  by  revealing  the  tuberculous 
nature  of  the  affection  by  appropriate  pathological  methods.  Noth- 
ing certain  can  be  said  of  the  diagnosis  of  glioma,  endothelioma, 
sarcoma,  etc. 

3.  The  Site  of  the  Tumor. — If  in  the  frontal  lobe  no  localizing  symp- 
toms will  be  recognized,  but  there  may  be  certain  alterations  in 
intellect  appreciable  by  the  patient's  family  or  intimates.  P>ontal 
lobe  tumors  often  are  found  at  autopsy  on  the  insane.  A  certain 
degree  of  incoordination  may  be  present,  affecting  the  equilibrium 
in  standing  or  walking,  and  causing  resemblance  to  cerebellar  tumors. 
A  tumor  in  the  motor  area  (anterior  to  the  Rolandic  fissure)  will 
produce  first  Jacksonian  epilepsy  (p.  590),  and  later  motor  paralysis 
of  the  opposite  side,  first  of  the  centres  nearest  the  growth,  and  later 
of  the  entire  motor  cortex  of  the  hemisphere  involved.  In  the  parietal 
lobe  (just  posterior  to  the  fissure  of  Rolando)  sensory  disturbances 
(such  as  loss  of  muscle  sense,  posture  sense,  etc.,  or  word  blindness) 
will  precede  Jacksonian  fits  and  loss  of  motion,  which  latter  phenomena 
will  result  when  the  tumor  reaches  such  a  size  as  to  press  upon  the 
cortex  or  subcortical  fibres  in  front  of  the  fissure  of  Rolando.  A 
tumor  in  the  superior  parietal  convolution  may  cause  astereognosis. 
A  tumor  of  the  occipital  lobe,  or  posterior  part  of  the  parietal  lobe, 
should  be  suspected  if  vision  is  affected  early  (homonymous  hemi- 
anopsia, sometimes  preceded  by  visual  hallucinations,  such  as  flashes 
of  light,  seeing  objects  upside  down,  etc.).  Tumors  in  the  temporo- 
sphenoidal  lobe  give  rise  to  deafness,  loss  of  taste  and  smell,  and  the 
convulsions  which  occur  often  are  preceded  by  a  sensory  aura.  Tumors 
at  the  base  of  the  brain  are  particularly  characterized  by  paralysis  of 
the  difi'erent  cranial  nerves,  as  well  as  by  hemiplegia,  hemianesthesia, 
etc.  Tumors  of  the  hypophysis  cerebri  may  produce  symptoms  of 
hyperpituitarism  (gigantism  in  infants,  acromegaly  in  adults)  or  of 
hypopituitarism  (adiposity,  with  infantilism  in  children,  and  loss 
of  sexual  characteristics  in  adults),  according  as  the  anterior  or 
posterior  portions  of  the  hypophysis  are  involved;  in  either  case, 
the  general  symptoms  of  brain  tumor  are  present,  together  with 
bitemporal  hemianopsia  from  pressure  on  the  optic  chiasm.  A  good 
skiagrai)h  may  demonstrate  increase  in  size  of  the  sella  turcica. 
Subtentorial  tvviors  may  be  within  the  cerebellum  or  may  grow  from 
the  meninges.  The  general  symptoms  occur  early,  and  are  constant 
and  severe;  and  in  addition  to  the  cardinal  symptoms  of  brain  tumor 
already  mentioned,  these  subtentorial  growths  are  characterized 
esjjecially  by  vertigo,  cerebellar  ataxia,  nystagmus,  etc.  Most 
symptoms  occur  on  the  same  side  as  the  lesion.  Of  the  extracere- 
bellar  tumors  those  growling  in  the  cerebeUoyontine  angle  are  most 
frequent;   usually  they  are  fibromas,  growing  from  the  sheath  of  the 


BRAIN   TUMOR 


585 


ci^litli  (Tiuiial  nerve,  and  cause  persistent  tiiniitus  aurinni,  and  d<>af- 
ness  ot"  th  •  same  side;  while  at  a  later  stage  they  cause  paralysis  ol'  the 
fifth,  sixth,  and  seventh  nerves,  and  may  finally  simulate  tumors 
within  the  cerehellum  (Fig.  ()25).  They  are  lightly  attached  by  a 
small  pedicle,  and  usually  can  be  enucleated  easily.  JntracereheUar 
iumors  are  characterized  l)y  the  early  development  of  vertigo,  changes 
in  the  eye-grounds  (sometimes  blindness  Ix'fore  ])a{)illedema).  and 
sensations  of  motion  of  self  or  of  surround- 
ing objects;  the  head  is  tilted,  usually 
toward  the  side  of  the  lesion,  and  there 
is  staggering  gait,  with  tendency  to  fall 
constantly  in  one  direction,  often  toward 
the  side  of  the  lesion.  The  ataxia  is  not 
increased  by  shutting  the  eyes.  It  is  more 
marked  in  tumors  of  the  vermis  than 
in  those  of  the  hemispheres.  Tumors  of 
the  yons  and  medulla  are  rapidly  fatal,  are 
not  amenable  to  operative  treatment,  and 
often  camiot  be  distinguished  from  cere- 
bellar growths. 

Treatment. — An  untreated  brain  tumor 
uniformly  leads  to  death.  Purely  medical 
treatment  is  inefi'ective  even  in  controlling 
the  most  distressing  symptoms,  pain  and 
blindness.  Operation,  merely  by  remov- 
ing the  overlying  cranium  and  thus  reliev- 
ing the  brain  of  pressure  {decovii^ession) 
may  cause  disappearance  of  all  symptoms 
for  an  indefinite  period,  even  restoring 
sight;  and  in  some  cases  the  tumor  can 
be  removed,  effectually  curing  the  patient. 
A  radical  operation,  including  removal  of 

the  tumor,  of  course,  always  is  to  be  preferred;  but  when  an  unlocalized 
tumor  exists,  making  its  presence  known  only  by  the  "syndrome  of 
brain  tumor,"  the  surgeon  should  not  hesitate  to  relieve  the  headache, 
check  the  vomiting,  and  prevent  the  development  of  blindness  or 
possibly  to  restore  sight  which  has  failed,  by  means  of  the  palliative 
operation.  This  operation  also  is  employed  when  a  tumor  is  found 
which  cannot  be  removed,  either  because  of  its  situation,  its  size,  or 
its  infiltrating  character. 

A  tumor  in  one  of  the  cerebral  hemispheres  is  exposed  by  the  forma- 
tion of  a  bone-flap  (the  so-called  osteoplastic  craniotomy,  p.  580), 
the  bone  being  replaced  after  the  removal  of  the  tumor.  If  no  tumor 
is  found,  or  if  it  cannot  be  removed  safely,  the  bone  is  removed  from 
the  flap,  thus  converting  the  operation  into  one  of  decompression. 
Indeed,  Horsley  never  replaces  the  bone-flap  even  after  the  tumor  has 
been  successfully  removed.  But  where  decompression  is  planned 
in  ach'ance,  the  subtemporal  operation  of  Cushing  is  to  be  preferred 


Fig.  625.  —  Tumor  in  right 
cerebollo-pontine  angle.  Age 
forty-nine  years.  Symptoms 
began  two  or  three  years  ago; 
worse  for  last  six  to  eight 
months,  since  which  time  there 
have  developed  ataxia,  deaf- 
ness, facial  paralysis,  and  loss 
of  eyesight.  (Paralysis  of  sixth, 
seventh,  eighth  nerves,  paresis 
of  ninth,  and  double  choked 
disk.)  (Dr.  F.  W.  Sinkler's 
patient.)    Orthopaedic  Hospital. 


586  sunaERY  of  the  head 

(p.  590).  A  tumor  beneath  the  tentorium  is  exposed  by  removal  of 
bone  from  one  or  both  occipital  fossa?;  and  the  bone  is  not  replaced. 
A  tumor  of  the  hypophysis  grows  either  toward  the  brain,  or  toward 
the  vault  of  the  pharynx;  this  usually  may  be  determined  by  skiagraphy. 
If  the  tumor  appears  accessible  from  within  the  cranium,  it  is 
best  approached  across  the  anterior  fossa  of  the  skull,  by  means  of  a 
frontal  bone-flap,  according  to  Frazier's  modification  of  McArthur's 
method  (1912):  a  large  bone-flap  with  external  base  is  elevated  from 
the  right  frontal  region,  and  the  supra-orbital  margin  and  roof  of 
the  orbit  are  temporarily  resected.  The  dura  covering  the  frontal 
lobe  is  then  elevated  from  the  base  of  the  anterior  fossa,  and  is  incised 
directly  over  the  pituitary  body.  The  sella  turcica  may  also  be 
approached  by  the  lateral  route,  elevating  the  temporal  lobe  from 
the  base  of  the  skull  after  removal  of  nearly  the  entire  side  of  the 
calvaria  (Horsley) ;  or  by  the  naso-frontal  route  of  Giordano,  employed 
by  Schloffer  (1907),  and  von  Eiselsberg  (1910);  or  by  the  m/ra-na^a/ 
method  of  Kanavel  (1909),  employed  by  Halstead  (1910)  and  by 
Mixter  (1910).  In  Halstead 's  operations  a  preliminary  tracheotomy 
was  done,  and  the  pharynx  was  tamponed.  Raising  the  upper  lip, 
an  incision  is  made  through  the  mucous  membrane  of  the  superior 
alveolus,  and  the  cartilaginous  septum  of  the  nose  is  divided.  The 
nose  is  then  retracted  upward.  After  the  bony  septum  and  turbinates 
have  been  excised,  the  anterior  wall  of  the  sphenoidal  sinus  is 
exposed  at  the  bottom  of  the  wound.  This  wall  being  broken 
through,  the  posterior  wall  is  identified.  This  lies  at  a  distance  of 
from  70  to  83  mm.  from  the  anterior  nasal  spine,  and  often  is  thinned 
by  the  growth  of  the  tumor  within  the  sella  turcica.  As  soon  as  the 
latter  cavity  is  opened,  the  tumor  tissue,  which  usually  is  fluid,  is 
evacuated  and  the  cavity  is  lightly  curetted.  The  tumor  cavity  and 
the  entire  wound  are  then  packed  with  iodoform  gauze,  which  emerges 
through  the  nostrils;  the  nose  is  replaced  and  retained  by  a  suture 
or  two,  and  finally  the  alveolar  mucous  membrane  is  sutured. 

Osteoplastic  Craniotomy,  or  Temporary  Resection  of  the  Skull  for 
Brain  Tumor. — The  strictest  aseptic  technique  is  requisite.  Hemor- 
rhage from  the  scalp  may  be  controlled  by  an  elastic  band  passed 
around  the  occipito-frontal  circumference  of  the  head.  The  "head- 
high"  position  lessens  venous  congestion.  A  skin-flap  is  outlined 
with  a  narrow  base  in  the  temporal  region,  the  flap  being  so  situated 
as  to  overlie  the  supposed  site  of  the  tumor.  The  tissues  of  the  scalp 
are  not  separated  from  the  underlying  bone,  which  is  cut  through  in 
the  same  lines  as  the  skin  incision.  Various  methods  are  employed 
for  dividing  the  bone:  Frazier  makes  a  trephine  opening  at  each  side 
of  the  base  of  the  flap,  and  cuts  the  margins  of  the  bone-flap  by 
Cryer's  spiral  osteotome  (1897),  which  is  a  side-cutting  rotatory 
fraise,  propelled  by  a  dental  engine  (Fig.  626) ;  Gushing  drills  holes  in 
the  bone  at  the  four  corners  of  the  bone-flap,  and  divides  the  bone 
along  the  top  and  each  side  of  the  quadrangular  flap  by  means  of  the 
Gigli  wire  saw  (1897),  which  cuts  from  within  outward  (Fig.  627); 


OSTEOPLASTIC  CRANIOTOMY 


587 


Fig.  626. — Cutting  the  bone-flap  by 
means  of  Oyer's  spiral  osteotome. 


Fig.  627. — Cutting  the  bone-flap  by  means  of 
the  Gigli  wire  saw.      (See  Fig.  4.S6.) 


Fig.  628. — Instruments  used  in  making  an  osteoplastic  flap  of  the  skull:  1.  Pe 
Vilbiss's  forceps;  2,  mosquito  hcmostat;  3,  ordinary  hemostat;  4,  Hudson's  trephine 
(see  p.  563),  with  four  bits:  5,  the  perforator;  6,  7,  8,  burrs  to  enlarge  the  original 
perforation.     (See  Fig.  629.) 


588 


SURGERY  OF   THE  HEAD 


others  use  a  bone  cutting  forceps,  like  a  very  narrow  rongeur,  which 
nips  out  a  channel  of  bone  around  the  margin  of  the  bone-flap  (Fig. 
628);  some  surgeons  use  a  mallet  and  chisel,  or  a  circular  saw  run  by 
a  dental  engine.  The  easiest  way  to  drill  the  holes  is  by  means  of 
Hudson's  trephine  (Fig.  ()29).  In  any  case,  after  the  top  and  two 
sides  of  the  bone-flap  have  been  cut  through,  its  narrow  base 
(composed  of  the  thin  bone  of  the  temporal  fossa)  is  fractured  by 
prying  up  the  bone-flap  by  two  bone  elevators  (Fig.  614,  3).  Bleeding 
from  the  diploe  is  controlled  by  application  of  minute  slips  of  muscle 
tissue  (cut  from  the  temporal  muscle)  or  by  plugging  with  Horsley's 
wax.  Archibald  uses  the  original  preparation:  beeswax,  7  parts;  almond 
oil,  1  part;  salicylic  acid,  1  part.  Hartley  preferred  this  formula: 
vaselin,  50  parts;  paraffin,  50  parts;  phenyl,  5  parts.    Some  surgeons 


Fig.  629. — Hudson's  trephine  in  use. 

prefer  to  do  this  operation  in  two  stages,  replacing  the  bone-flap  and 
postponing  exploration  for  the  tumor  until  some  days  later;  but 
unless  unexpected  difficulty  or  delay  has  attended  the  formation  of 
the  bone-flap,  it  is  better  to  conclude  the  operation  in  one  sitting.^ 

The  dura,  being  thus  exposed  over  a  wide  area,  is  incised  concentric- 
ally with  the  bone,  leaving  a  sufficient  margin  to  facilitate  closing 
it  again  by  suture.  When  the  cerebral  cortex  is  exposed,  the  tumor 
may  be  found  on  its  surface;  it  then  usually  is  lightly  attached,  and 

1  dishing  has  found  that  the  second  stage  of  such  an  operation  may  be  con- 
ducted without  the  use  of  any  anesthetic,  except  "primary  anesthesia"  for  suturing 
the  skin-flap  at  the  end  of  the  operation,  since  the  dura  and  cortex  are  totally 
insensitive  to  gentle  manipulation. 


DFA'OMI'UKSSIVI-:   (U'Mh'ATlOX    I'OU    liUMX    TCMOR 


:).S!) 


may  he  (Miiiclcatcd.  If  no  tumor  is  visible,  it  is  jiistifiahic  to  explore 
the  suheortical  region.  It  is  extremely  important  to  control  liemor- 
riiage  from  the  pial  vessels;  any  bleeding  points  should  be  caught 
in  mosquito  hemostats  (Fig.  ()2S)  and  ligated  or  sutured  with  very 
fine  silk.  Sometimes  it  is  sufficient  to  apply  mimite  slips  of  muscle 
tissue.  To  explore  the  subcortical  region  an  incision  with  scalpel  is 
made  in  lhe  middle  of  a  convolution  free  of  vessels,  and  if  an  encap- 
sulated tumor  is  found  it  is  shelled  out  by  blunt  dissection;  a  cyst 
should  be  evacuated  and  its  lining  wall  removed  if  this  is  possible 
without  trauma.  A  diffusely  infiltrating  growth  should  not  be 
removed.  I  have  seen  a  surgeon  scoop  out  spoonful  after  spoonful 
of  tissue  from  one  cerebral  hemisphere  which  was  pronounced  by 
several  distinguished  neurologists  who  were  present  to  be  typically 
gliomatous  in  appearance;  yet  microscopical  study  j)roved  the  tissue 
removed  to  l)e  normal  cerebral  substance,  while  at  autopsy  the  tumor 
was  found  in  a  totally  different  part  of  the  brain.  Hemorrhage  from 
the  brain  substance  is  controlled  by  extremely  gentle  irrigation 
with  hot  (115°  to  120°  F.)  saline  solution,  or  by  light  pressure  with 
pledgets  of  dry  absorbent  cotton,  or  the  application  of  muscle  tissue. 
The  dural  flap  is  then  sutured  as  accurately  as  possible ;  the  bone-flap 
is  replaced,  and  the  skin  is  sutured  tightly  with  closely  set  interrupted 
sutures  of  silkworm  gut,  which  control  all  bleeding  from  the  scalp. 
Never  hurry,  and  use  only  extremely  gentle  manipulations  in  brain 
surgery.  Keep  the  wound  free  from  blood,  and  avoid  drainage 
whenever  possible. 


H                         ^B 

*^"    3 

M^'*       ^1 

^■-^y 

Fig.  630. — Cicatrix  of  operation  by 
osteoplastic  flap,  for  middle  meningeal 
hemorrhage.  Age  fourteen  years.  (Dr. 
Frazier's  case.)     Episcopal  Ho.spital. 


Fig.  631.  —  Hernia  cerebri  three 
months  after  operation  for  cerebral 
tumor.  (Dr.  W.  .J.  Taylor's  case.) 
Orthopaedic  Hospital. 


Decompressive  Operation  for  Brain  Tumor.— As  stated  already, 
an  osteoplastic  craniotomy  may  be  converted  into  a  decompressive 
operation  by  removal  of  bone  from  the  flap,  replacing  only  the  tissues 


590  SURGERY  OF   THE  HEAD 

of  the  scalp.  The  ckiral  flap  which  has  been  turned  down  for  the 
purpose  of  exploration,  is  replaced  but  is  not  sutured,  and  the  brain 
bulges  into  the  opening,  relieving  the  intracranial  pressure,  and  is 
covered  only  by  the  tightly  sutured  scalp.  Such  a  i)rotrusion,  known 
as  hernia  cerebri,  may  be  very  unsightly  (Fig.  631),  and  as  the  tumor 
continues  to  grow  the  hernia  may  become  immense,  and  may  cause 
sloughing  of  the  overlying  scalp,  with  secondary  infection  of  the 
cerebral  substance.  A  better  operation,  when  decompression  is 
planned  in  advance,  is  the  subtemporal  decompressive  operation  of 
Gushing:  in  this  a  flap  of  skin  is  turned  down  over  the  temporal 
fossa,  exposing  the  temporal  muscle  covered  by  its  aponeurosis; 
these  structures  are  then  divided  down  to  the  bone  in  a  straight 
line  parallel  to  the  muscular  fibres,  from  temporal  ridge  to  zygoma; 
by  retracting  the  muscle  a  fairly  large  area  of  cranium  is  exposed; 
this  is  trephined,  and  the  opening  is  enlarged  by  rongeur  forceps 
and  the  dura  is  incised  around  the  margin  of  the  skull  opening.  The 
muscle  and  the  skin-flap  are  then  sutured,  without  drainage.  The 
hernia  cerebri,  which  results,  protrudes  beneath  the  temporal  muscle, 
which  acts  as  support,  rendering  the  deformity  much  less  conspicuous. 
Frazier  employs  a  similar  decompressive  operation  on  the  occipital 
bone,  in  cases  of  inoperable  cerebellar  tumors.  It  may  be  impossible 
to  close  the  scalp,  in  some  cases  of  inoperable  brain  tumor,  after  de- 
compression has  been  accomplished,  owing  to  the  protrusion  of  the 
hernia  cerebri ;  but  if  necessary  this  may  be  diminished  by  elevating 
the  patient's  head,  or  even  by  lumbar  or  ventricular  puncture. 

Patients  may  live  for  months  or  years  after  a  decompressive  opera- 
tion, being  symptomatically  relieved  until  rapid  death  results  from 
some  incurable  complication. 

Fungus  Cerebri  should  be  distinguished  from  hernia  cerebri, 
mentioned  above.  The  former  is  an  old  term  which  it  is  convenient 
to  retain  to  describe  granulations  ("proud  flesh")  springing  from 
cerebral  substance  exposed  in  a  wound,  and  developing  as  the  result 
of  infection.  Fungus  cerebri  may  occur  in  cases  of  compound  frac- 
ture, with  rupture  of  the  dura  and  protrusion  of  brain  substance; 
or  in  cases  of  hernia  cerebri  secondarily  infected  from  sloughing  of 
the  overlying  scalp.  The  treatment  consists  in  antiseptic  and  astrin- 
gent applications,  of  which  alcohol  is  the  most  efi^ective.  This  grad- 
ually causes  the  granulations  to  shrivel  up.  If  the  fungus  is  cut  off 
with  scissors  it  will  soon  return  unless  the  infection  is  controlled  and 
the  wound  begins  to  cicatrize  and  contract. 

Focal  or  Jacksonian  Epilepsy,  named  after  Hughlings  Jackson, 
who  particularly  studied  the  condition  in  1873,  was  referred  to  at 
p.  584,  as  an  occasional  symptom  of  brain  tumor.  It  is  characterized 
by  convulsive  attacks  beginning  in  one  muscle  or  group  of  muscles, 
gradually  spreading  until  finally  a  generalized  convulsion  ensues. 
Consciousness  may  persist  until  the  convulsions  become  general, 
or  it  may  not  be  lost  at  all.  It  is  thus  distinguished  from  ordinary 
("idiopathic")  epilepsy,  in  which  the  fits  are  general  from  the  first, 


FOCAL  EPILEPSY  591 

and  in  which  unconsciousness  ushers  in  the  attack.*  Jacksonian 
epilepsy  is  believed  to  be  due  either  to  some  localized  cortical  lesion, 
or,  rarely  (and  then  most  often  in  children  and  women),  to  some 
peripheral  sensor}'  irritation,  arising  from  a  painful  cicatrix  or  other 
lesion  such  as  eye-strain,  dental  disorders,  genital  affections,  etc. 

In  cases  due  to  cortical  lesion  the  most  frequent  cause,  apart  from 
tumor,  is  the  result  of  old  trauma;  this  may  have  been  a  depressed 
fracture,  or  a  meningeal  hemorrhage  producing  a  meningo-cortical 
adhesion,  a  cyst,  or  a  cicatrix.  Similar  lesions  may  be  the  result 
of  intracranial  infections,  especially  in  children,  in  whom  focal  epilepsy 
may  develop  after  an  attack  of  meningitis,  poliomyelitis,  etc. 

Treatment. — x\s  there  is  no  medical  cure  for  these  cases,  it  is  per- 
fectly justifiable  to  consider  what  benefits  may  be  gained  from  surgical 
intervention  if  a  definite  lesion  can  be  located.  Nor  should  the 
surgeon  hesitate  to  operate  for  any  surgical  condition  in  another 
part  of  the  body  in  an  epileptic  patient  merely  because  occasional 
fits  occur;  for  it  happens  occasionally  that  cure  of  a  lesion  not  sus- 
pected of  having  any  causal  relation  with  the  epilepsy  results  in 
freedom  from,  or  at  least  in  a  lessening  in  frequency  of  the  convulsions. 

If  a  meningeal  or  cortical  lesion  is  suspected,  the  centre  controlling 
the  muscle  group  first  aflfected  is  exposed  by  an  osteoplastic  flap. 
Depressed  bone  is  removed;  adherent  dura  is  excised,  and  the  re- 
formation of  adhesion  is  prevented  by  the  interposition  of  Cargile 
membrane,  silver  foil,  or  similar  substance.  Free  transplants  of 
fascia  lata  have  been  used  with  success.  Little  can  be  done  for  lesions 
in  the  cerebral  substance.  The  proper  centre  may  be  identified  by 
faradization  of  the  cortex.  Kocher  (1899)  believed  a  decompression 
operation  alone  was  of  benefit.  The  sooner  any  operation  is  done 
after  the  development  of  focal  epilepsy,  the  more  apt  is  it  to  be  cura- 
tive; and  if  all  head  injuries  received  efficient  treatment  at  the  time 
of  the  original  accident,  the  number  of  cases  of  Jacksonian  epilepsy 
would  be  much  decreased. 

1  Advances  in  knowledge  constantly  are  diminishing  the  number  of  cases  of  true 
"idiopathic"  epilepsy,  and  it  is  not  impossible  that  only  our  ignorance  prevents 
a  recognition  of  an  organic  lesion  in  all  such  cases. 


CHAPTER  XVIII. 
SURGERY  OF  THE  SPINE. 

Spina  Bifida,  or  Hydrorrachis.— Under  these  names  are  included 
several  forms  of  congenital  malformation  oi  the  spine,  due  to  failure 
of  proper  coalescence  in  the  embryonal  medullary  plates.  Myelocele, 
or  Rachischisis,  is  the  most  complete  form.  In  this  the  skin  is  defi- 
cient, and  there  is  exposed  on  the  back  of  the  infant,  usually  in  the 
lumbar  region,  a  dark  red  area  covered  by  endothelium,  which  is  con- 
tinuous above  and  below  with  the  central  canal  of  the  spinal  cord. 
The  infant  often  presents  other  serious  malformations,  and  usually 
is  stillborn  or  dies  within  a  few  days  from  continual  leakage  of 
cerebrospinal  fluid,  or  from  infection.  Syringomyelocele:  Here  the 
central  canal  of  the  spinal  chord  is  distended  with  fluid,  the  surround- 
ing chord  is  compressed  and  atrophic,  and  protrudes  as  a  cystic  tumor 
through  a  defect  in  the  vertebral  laminae.  The  protrusion,  which  is 
covered  by  skin,  or  membrane,  usually  occurs  to  one  side,  and  not 
in  the  midline.  Moiingomyelocele  is  by  far  the  commonest  of  these 
deformities,  occurring  in  nearly  two-thirds  of  all  cases  of  spina  bifida. 
The  cystic  protrusion  is  formed  by  fluid  which  collects  in  the  meshes 
of  the  arachnoid,  and  the  roots  of  the  spinal  nerves  are  spread  out 
over  the  walls  of  the  sac.  If  the  sac  presents  a  dimple  or  furrow  on  its 
surface  it  is  probable  that  the  cord  itself  is  adherent.  The  laminae  of 
one  or  several  vertebrae  may  be  deficient.  Meningocele,  in  which  the 
protrusion  involves  only  the  spinal  membranes,  and  never  the  nerve 
roots  or  the  cord  itself,  occurs  only  in  about  8  per  cent,  of  cases. 
The  tumor  is  small,  covered  throughout  with  healthy  skin,  never 
presents  a  dimple  or  a  furrow,  and  usually  is  more  or  less  pedunculated, 
its  orifice  of  communication  with  the  spinal  canal  being  small.  In 
meningomyelocele,  on  the  contrary,  the  protrusion  is  large,  sessile, 
and  communicates  with  the  spinal  canal  through  a  large  defect;  and 
while  healthy  skin  may  extend  upward  from  its  base  some  distance,  the 
summit  of  the  protrusion  usually  is  covered  by  membrane  which  easily 
becomes  inflamed  and  sloughing  is  frequent.  Paralysis  of  the  parts 
below  the  tumor  points  to  a  condition  of  meningomyelocele  rather 
than  of  pure  meningocele.  If  there  is  a  defect  in  the  bony  wall  of  the 
vertebral  canal,  without  the  protrusion  of  any  of  its  contents,  the 
condition  is  known  as  Spina  Bifida  Occulta;  this  usually  is  accom- 
panied by  hypertrichosis  of  the  region  affected.  In  very  rare  cases 
there  has  been  a  defect  in  the  anterior  portions  of  the  vertebral  canal, 
constituting  Spina  Bifida  Anterior. 

Symptoms. — Besides  the  presence  of  a  cystic  growth,  usually  in  the 
lumbar  or  sacral  regions  of  the  spine,  it  may  be  possible  to  ascertain 


INJURIES  OF  TllK  SI'IXE 


693 


by  j)ali)ati()ii  or  .skiu|;raphic  exaniimitioii  that  a  defect  exists  in  tlie 
vertebra?.  Compression  of  the  spina  bifida  usually  causes  increased 
tension  in  the  cranial  fontanelles,  and  may  prcjduce  convulsions. 
Tension  of  the  cyst  is  increased  durinfi;  expiration,  and  when  the  child 
is  in  the  npri<;ht  position. 

Treatment. — 1.  //  tJicre  are  oilier  serious  malforiiiatioiis,  or  extensive 
parah/sis,  no  radical  treatment  should  be  adopted,  as  most  of  these 
patients  will  die  within  the  first 
year  under  any  circumstances. 
Efforts  to  avoid  infection  should 
be  made,  by  preventing  excori- 
ation of  the  sac.  If  such  patients 
survive  more  than  five  years, 
operative  treatment,  as  detailed 
below,  will  be  proper.  2.  //  there 
are  no  other  serious  malformaiions 
and  no  parali/ses,  the  treatment  to 
be  adopted  depends  upon  the  con- 
dition of  the  coverings  of  the  spina 
bifida:  when  these  are  healthy,  as 
in  most  cases  of  pure  meningocele, 
operation  should  be  postponed  until 
the  child  is  five  years  of  age;  when 
the  coverings  are  thin  or  membran- 
ous, the  risk  from  delay  is  as  great 
as,  if  not  greater  than  that  from 
early  aseptic  operation.  Imme- 
diate operation  may  be  required  at  any  time  for  rupture  of  the  sac, 
but  when  a  choice  is  possible,  operation  during  the  second  or  third 
month  of  life  is  to  be  preferred  (Lovett,  1907). 

Operation  usually  consists  in  excision  of  the  sac,  preserving  healthy 
skin  coverings,  and  carefully  dissecting  free  adherent  nerves,  but 
cutting  away  those  that  cannot  be  preserved,  as  the\'  probablj'  are 
functionless  (Carson).  The  sac  walls  are  then  overlapped,  as  in  radical 
cure  of  umbilical  hernia,  and  the  muscles  and  skin  are  sutured  in 
separate  layers,  and  the  wound  is  closed  tightly  without  drainage. 
The  death  rate  following  operation  is  from  25  to  35  per  cent.,  and 
hydrocephalus  sometimes  develops  as  a  result.  Reference  was  made 
at  p.  556  to  Heile's  employment  of  drainage  of  the  sac  into  the  peri- 
toneal cavity  by  means  of  subcutaneous  silk  threads,  with  coincident 
cure  of  a  complicating  hydrocephalus. 

Sacro-coccygeal  Tumors. — See  Chapter  IV. 


032. — Spina    bifida.     Age    eightceu 
months.     Orthopaedic  Hospital. 


INJURIES  OF  THE  SPINE. 

Strains. — Strains  of  the  back,  affecting  the  muscular  and  aponeu- 
rotic structures,  are  much  more  frequent  than  true  sprains  affecting  the 
spinal  joints.    According  to  the  severity  of  the  injury,  these  patients 
38 


594  SURGERY  OF   THE  SPIXE 

are  to  be  treated  by  rest  in  bed,  or  as  ambulatory  cases,  support  being 
provided  during  the  painful  stages  by  adhesive  plaster  strapping  or 
plaster  of  Paris  jackets.  Restoration  of  function  may  be  aided  later 
by  massage. 

Sprain-fracture. — Sprain-fracture  of  the  transverse  processes  of  the 
lumbar  vertebrae,  unilateral,  occasionally  occurs  from  muscular  action. 
Tanton  (1910)  has  collected  17  cases  of  this  injury.  Skillern  (1913) 
has  reported  a  case  of  sprain-fracture  of  a  spinous  process. 

Static  Lesions  of  the  Lumbar  Spine  and  Spondylolisthesis  are 
discussed  in  Chapter  X\'I. 

Concussion  of  the  Spinal  Cord. — This  term  has  been  used  to 
define  a  condition  supposed  to  be  more  or  less  analogous  to  con- 
cussion of  the  brain  fp.  569).  It  implies  that  there  has  been  injury 
to  the  spinal  cord  without  lesion  of  the  vertebral  column;  and  while 
some  hold  that  the  symptoms  which  follow  a  supposed  injury  have  no 
pathological  basis  for  their  existence,  being  merely  one  form  of  neurosis, 
other  authorities  believe  that  actual  changes  in  the  cord  have  taken 
place,  and  have  left  more  or  less  irreparable  damage.  Many  of  these 
patients  receive  their  injury  in  railroad  accidents,  and  the  condition 
which  ensues  is  popularly  known  as  "Railway  Spine,"  or,  because  of 
the  improvement  which  usually  follows  the  settlement  of  a  suit  for 
damages,  as  "Litigation  Spine."  As  a  matter  of  fact  it  is  probable  that 
most  of  these  cases  should  be  considered  severe  strains  or  sprains  of 
the  back,  and  the  surgical  treatment  is  the  same.  For  the  hysterical 
symptoms  which  sometimes  ensue,  the  patients  should  be  referred 
to  a  neurologist. 

Hematomyelia. — Hematomyelia,  or  hemorrhage  into  the  substance 
of  the  spinal  cord,  sometimes  occurs  from  sudden  twists  or  angula- 
tions of  the  vertebral  column,  perhaps  from  a  self-reduced  subluxation, 
without  discoverable  gross  lesion  of  the  spinal  column.  It  is  seen 
oftenest  in  the  lower  cervical  region  (Thorburn,  1S89).  and  causes 
paralysis  depending  upon  the  extent  of  the  lesion.  Usually  the  lower 
extremities  recover  from  the  paralysis  more  or  less  rapidly,  though 
they  may  remain  spastic,  while  the  flaccid  paralysis  of  the  upper 
extremities  continues.  There  is  dissociated  anesthesia  below  the 
level  of  the  lesion:  that  is,  while  tactile  sensation  is  preserved,  tem- 
perature and  pain  sense  are  diminished  or  lo-t.  Spinal  puncture 
shows  nf)  blood  in  the  cerebrospmal  fluid. 

Stab  Wounds. — Stab  wounds,  involving  the  spinal  cord  are  very 
rare.  From  unilateral  lesion  a  monoplegia  may  result.  It  is  best 
in  civil  life  to  explore  such  wounds,  by  laminectomy  (p.  601),  as  it 
may  be  possible  to  repair  the  injury. 

Fractures  and  Dislocations  of  the  Spinal  Column. — Fracture  and 
dislocation  occur  as  a  combined  lesion  in  about  (^0  per  cent,  of  cases 
of  injury  of  the  spinal  column,  while  isolated  fractures  and  disloca- 
tions form  each  about  20  per  cent,  of  these  injuries.  The  spine  is 
most  subject  to  injury  where  its  mobile  and  immobile  portions  meet, 
that  is,  in  the  lower  cervical  and  the  dorso-lumbar  regions.     Pure 


IXJIRIES  OF  rilE  SPINE 


595 


dislocations  are  very  rare  except  in  the  cervical  rej^ion,  as  the  form  of 
the  articular  processes  renders  fracture  almost  a  necessary  complica- 
tion in  other  portions  of  the  vertebral  column.  Fractures  of  the  laminae 
or  spiiH.us  processes  usually  occur  from  direct  \iolcnce,  as  in  jiuiishot 
wounds,  or  in  falls  from  a  height  directly  upon  the  hack,  impiuf^dnj^ 
on  a  stone,  fence  rail,  etc.  The  most  common  lesion  is  a  crushing 
fracture  of  the  bodies  of  one  or  more  vertebra^,  attended  by  forward 
dislocation  of  the  vertebra  next  above,  the  disjunction  of  the  articular 
j)r()cesses  taking  place  on  one  or  both  sides  (Fig.  b.'33).  Such  cases 
generally  are  caused  by  sudden  hyperflexion,  with  twist,  of  the  spinal 
column,  as  falls  from  a  height  on  to  the  feet  or  the  buttocks,  crushing 
injuries  from  above  acting  upon  the  shoulders,  or  from  a  dive  into 
shallow  water,  ^'iolence  acting  upon  the  head  or  neck  usually  pro- 
duces a  lesion  in  the  lower  cervical  region,  and  that  acting  from  Ijelow 
determines  lesions  in  the  dorso-lumbar  portion  of  the  spine. 


^■l.       >^     ^^^^H 

^^^^^^^SS^^flH 

P'lG.  t)33.- — Fracture  dislocatirm  of  eleventh  and  twelfth  thoracic  vertebrae.     From   a 
specimen  in  the  Mutter  Museum  of  the  College  of  Physicians  of  Philadelphia. 

Symptoms. — These  may  be  divided  into  those  due  to  injury  of  the 
vertebral  column,  and  those  caused  by  accompanying  lesions  of  the 
spinal  cord.  It  is  said  that  the  cord  escapes  injury  in  about  one-third 
of  the  cases. 

Symptoms  from  Injury  of  the  Vertebral  Column. — Of  these,  deformity 
is  of  most  value.  This  may  consist  in  a  depression  at  the  point  of 
injury,  especially  when  the  fracture  is  from  direct  violence,  the  spines 
and  laminae  being  driven  forward;  or  it  may  indicate  that  there  is  a 
partial  forward  dislocation  of  the  vertebra  whose  spine  is  depressed. 
Such  a  depression  is  most  apt  to  be  found  in  a  dorso-lumbar  injury. 
In  some  cases  there  is  angular  deformity,  a  well  defined  kyphos  existing 


596 


SURGERY  OF   THE  SPINE 


at  the  point  of  injury  and  indicating  the  collapse  of  a  vertebral  body, 
causing  separation  of  the  spinous  processes.  Rotatory  deformity  is 
seen  oftenest  in  the  cervical  region,  in  cases  of  unilateral  dislocation: 
the  head  is  twisted  away  from  the  side  which  is  luxated,  and  this 
side  maj'  be  unduly  prominent;  the  sterno-mastoid  muscle  on  the 
uninjured  side  is  more  tense  than  is  that  on  the  injured  side.  Other 
symptoms  of  fracture,  such  as  mobility  and  crepitus,  seldom  are 
present;  but  persistent  localized  tenderness  is  very  suggestive  of 
vertebral  injury,  and  in  the  cervical  region  muscular  spasm,  producing 
rigidity  of  the  neck,  is  a  very  usual  symptom,  especially  in  lesions  of 
the  vertebrne  without  injury  of  the  cord.  A  good  skiagraph  may  be 
necessary  to  assure  the  diagnosis  in  obscure  cases. 

Symptoms  from  Injury  of  the  Spinal  Cord.  Motor  Symptoms. — Motor 
paralysis  is  the  most  striking  and  one  of  the  most  constant  symptoms, 

and  involves  all  the  muscles  below  the 
seat  of  the  lesion.  Usually  it  follows 
the  injury  immediately,  and  then  indi- 
cates extensive  destruction  of  the  cord, 
as  a  rule  from  crush  due  to  displaced 
l)one  (Fig.  634).  If  the  onset  of  the 
paralysis  is  delayed,  it  probably  is  the 
result  of  hemorrhage  either  within  the 
cord  {hematomyelia)  or  in  the  arach- 
noid spaces.  The  former  has  been  con- 
sidered above;  in  the  latter,  which  is 
known  as  hematorrachis,  paralysis  of 
motion  usually  is  more  marked  than  is 
that  of  sensation,  and  gradually  ex- 
tends upward,  perhaps  in  the  course  of 
a  few  hours.  In  all  cases  the  primary 
paralysis  is  flaccid,  and  the  patient 
is  free  from  pain,  at  least  in  the  early 
stages.  If  the  paralysis  becomes  spastic 
very  soon  (12  to  24  hours)  after  the 
injury,  and  if  the  reflexes  are  present, 
it  usually  indicates  only  partial  de- 
struction of  the  cord,  from  contusion, 
pressure  from  displaced  bone,  hematorrachis,  etc.  Paralysis  which 
first  develops  some  days  after  a  spinal  injury  usually  is  due  to 
inflammatory  exudation  or  blood-clot.  But  lumbar  puncture  rarely 
shows  blood  in  the  cerebrospinal  fluid. 

In  the  cervical  region,  symptoms  of  cord  injury  may  be  obscured 
at  first  by  those  due  to  cerebral  concussion,  caused  by  the  same  injury. 
If  the  lesion  is  above  the  fourth  cervical  segment,  causing  paralysis 
of  the  diaphragm,  immediate  or  rapid  death  is  usual.  Symptoms 
from  paralysis  of  the  cervical  sympathetic  may  be  present.  Char- 
acteristic attitudes  may  be  assumed  owing  to  unopposed  action  of 
intact  muscles  (Fig.  635). 


Fig.  G34.  —  CrushiiiK  fracture  of 
first  lumbar  vertebra.  Mutter 
Museum. 


IXJlh'lIiS  OF  HIE  SI'INE 


of)^ 


It"  the  lesion  is  below  llie  .-ecoiid  lumbar  \ertebra,  i)aralysis  may  be 
absent  or  only  partial,  o\viii<;  to  the  fact  that  the  spinal  eord  itself 
does  not  extend  beyond  tliis  lex'el,  and  the  injury  may  invohc  only 
some  of  the  branches  of  the  eauda  ('(juina.  In  rare  eases  onl\'  unilateral 
(homolateral)  paralysis  may  exist;  this  is  much  more  usual  in  stab 
and  gunshot  wounds  than  in  eases  of  fraeture-disloeation. 

At  a  later  date  (after  a  week  or  ten  days)  it  is  very  usual  for  the 
patient  to  experience  i)ainful  spasms  in  the  paralyzed  limbs;  and  as 
cicatricial  chanf:;es  in  the  cord  progress  the  type  of  paralysis  becomes 
spastic,  and  contractures  develop  (Fig.  244). 


Fig.  635. — Fracture  of  cervical  vertebrae.  Characteristic  position  of  arms  when  the 
lesion  is  above  the  fourth  cervical  segment.  (Thorburn's  position.)  (See  Fig.  6.36.) 
Episcopal  Hospital. 

Sensory  Symptoms. — Sensation  is  lost  over  an  area  corresponding 
to  that  of  paralysis  of  motion,  and  the  upper  limit  of  the  motor  and 
sensory  paraly.sis  is  sharply  defined,  thus  determining  the  level  of  the 
injury  (Fig.  63()).  Pain  rarely  is  severe,  though  a  zone  of  hyperesthesia 
is  not  infrequent  at  the  upper  border  of  the  anesthetic  area.  Shooting 
pains,  from  irritation  of  the  sensory  nerve  roots,  are  more  common 
in  partial  cord  lesions,  and  often  occur  when  recovery  from  severer 
lesions  is  beginning.  Dissociated  anesthesia,  as  already  mentioned, 
is  frequent  in  hematomyelia. 

Bed-sores,  especially  over  the  sacrum  and  heels,  are  very  prone  to 
develop  in  cases  of  spinal  injury,  being  described  as  due  to  trophoneu- 
rotic disturbances.  Whatever  is  the  true  explanation,  the  probability 
of  their  early  development  (within  two  or  three  days)  always  should 
be  borne  in  mind,  and  preventative  measures  instituted. 

Abdominal  and  Vesical  Symptoms, — Owing  to  the  motor  paralysis 
affecting  the  muscles  of  the  abdominal  wall,  and  perhaps  the  muscular 
tunics  of  the  intestines,  tympanites  develops.    If,  as  is  usual,  the  lesion 


598 


SURGERY  OF   THE  SPINE 


N.  to  sphincte 
Coccygeal  n 


_iV.  to  rectus  lateralia 
^'Ito  rectus  antic,  minor 
^AiuistuDiosis  Willi  hyijorjlassal 

_  Anastomosis  with  pnetnnngastric 

_N.  to  rectus  antic. major. 
..N.  to  mastoid  region. 
._Great  auricular  n. 

-Transverse  cervical  n. 
N.  to  Trapezius,  Any.  Scap.  and  Rhomboid. 

,Supra-ctavicular  n. 

.Supra-acrumial  n. 

.Phrenic  n. 

N.  to  levator  any.  scap. 

^V.  to  rhomboid 

.  —  Subscapular  n. 

. _  Subclavicular  n. 


X.  to  peetoralis  major. 


Circumflex  n. 

^^Musculo-cutaneou.-i  u. 

Median  n. 

Radial  n. 

_Ulnar  n. 

_laternal  cutaneous  ». 

..Small  internal  cutaneous  i 


Ilio-hijpocjaxtric  n. 
lUo-inguinat  n. 


Ejcternal  cutaneous  n 
Genito-crural  n. 


Anterior  crural  i 
Obturator  n. 


Superior  gluteal  n. 


-N.  to pyriformis 
.N.  to  gemellus  super. 


Small  sciatic  n. 
S'Jiatic  n. 


Fig.  636. — The  relation  of  the  segments  of  the  spinal  cord  and  their  nerve  roots  to 
the  bodies  and  spines  of  the  vertebrae.  (Dejerine  et  Thomas,  Mai.  d.  1.  Moelle  Epinifere, 
Paris     1902.) 


INJLIHES   OF   'rilK  Sl'lSK  599 

is  above  the  spinal  centres  for  tlie  bladder  and  rectum  (in  the  second, 
third,  and  fourth  sacral  se<2;ments),  there  is  rHeniion  uitit  ovcrjloir  (.f 
the  urine  and  feces,  as  the  voluntary  impulses  from  the  cerebrum 
cannot  reach  the  spinal  centres,  and  the  sphincters  remain  tonicaily 
contracted  until  overflow  occurs.  The  bladder  becomes  distended, 
and  only  the  surplus  urine  dribbles  away;  feces  accunuilate  in  the 
rectiun,  and  this  is  emj)tied  only  by  enema,  or  finally  by  exhaustion 
of  the  sphincter.  If,  however,  what  is  very  rare,  the  lesion  is  so 
low  as  to  damatije  these  centres  themselves,  or  the  nerves  between 
them  and  the  bladder  or  rectum,  then  true  incontinence  of  urine  and 
feces  occurs,  the  bladder  remaining  empty,  while  the  urine  and 
feces  are  passed  in\oluntarily,  and  more  or  less  continuously.  Ci/n- 
iitis  is  very  hard  to  prevent,  as  a  consequence  of  the  habitual  use  of 
the  catheter  which  is  required  as  long  as  retention  persists.  Fnnpisin, 
occurring  soon  after  the  injury,  is  common,  especially  in  younger 
patients,  and  is  said  to  be  more  frequent  in  severe  and  high  lesions 
than  in  those  at  a  lower  level,  or  those  in  which  there  is  only  partial 
destruction  of  the  cord. 

Prognosis. — It  long  has  been  a  rule  of  thumb  that  when  the  frac- 
ture is  in  the  cervical  spine  the  patients  will  live  a  week,  those  with 
fracture  of  the  thoracic  spine  a  month,  and  those  with  fracture 
of  the  lumbar  spine  a  year;  and  this  may  still  be  considered  a  fairly 
accurate  prognosis  when  there  is  evidence  of  complete  transverse 
lesion  of  the  cord.  But  in  the  cervical  region  it  is  not  unusual 
for  the  cord  to  escape  injury,  mainly  owing  to  the  large  size  of  the 
spinal  canal.  J.  and  A.  Boeckel  (1911)  have  collected  36  such  cases. 
In  injuries  of  the  thoracic  and  lumbar  regions,  life  may  be  preserved 
indefinitely  if  such  complications  as  bed-sores,  cystitis,  and  pyoneph- 
rosis can  be  prevented;  and  if  the  cord  is  not  totally  destroyed,  careful 
nursing  may  enable  a  certain  amount  of  power  to  be  regained. 

Treatment. — No  hesitancy  should  be  felt  in  reducing  any  deformity 
present,  especially  in  the  cervical  region;  but  this  should  be  done 
judiciously,  and  with  a  clear  idea  of  the  mechanism  of  the  injury. 
The  fact  that  one  or  more  such  attempts  have  resulted  in  the  patient's 
immediate  death,  demonstrated  nothing,  as  pointed  out  by  Mal- 
gaigne,  as  long  ago  as  1843,  but  that  the  attempts  were  unskilfully 
made  by  an  incompetent  person.  In  studying  nearly  400  cases  of 
spinal  injury,  John  Ashhurst,  Jr.  (1867)  found  that  in  the  treatment 
of  dislocations  in  the  cervical  region  the  mortality  had  been  nearl}^ 
four  times  greater  when  no  attempts  were  made  to  reduce  the 
deformity,  than  when  this  was  undertaken  by  extension,  rotation, 
etc.  Walton  (1892)  systematized  the  reduction  of  these  injuries, 
omitting  attempts  at  extension  (longitudinal  traction),  which  he 
demonstrated  to  be  useless,  and  employing  only  "  retro-lateral  flexion 
and  rotation,"  in  the  unilateral  cervical  dislocations,  which  are  the 
most  frequent  cases.  Reduction  is  accomplished,  after  etherizing 
the  patient,  in  this  manner:  the  surgeon  stands  behind  the  seated 
patient,  and  grasps  the  head  between  his  hands;  the  head  is  then 


600  SURGERY  OP  THE  SPINE 

tilted  backward,  and  flexed  slightly  away  from  the  dislocated  side, 
so  as  to  release  the  dislocated  articular  process  from  the  interver- 
tebral foramen  of  the  vertebra  next  below,  where  it  is  usually  caught. 
The  head  is  then  rotated  so  as  to  carry  the  dislocated  side  ))ackward. 
Reduction  of  the  deformity  may  be  attended  by  an  audible  or  pal- 
pable click.  The  patient  should  remain  in  bed,  with  the  head  and 
neck  immobilized  by  plaster  of  Paris  dressings,  or  by  sand-bags  with 
weight  extension  (as  in  cervical  Pott's  disease,  p.  609)  for  a  couple 
of  weeks,  and  some  retentive  appliance  should  be  worn  for  some 
weeks  longer,  or  until  the  ruptured  ligaments  have  had  a  chance  to 
heal.  Bilateral  cervical  dislocations  may  be  reduced  by  the  same 
method,  applied  to  each  side  separately.  The  deformity  from  frac- 
ture, seldom  present  except  in  the  thoracic  and  lumbar  regions, 
usually  is  best  corrected  by  hyperextension  of  the  spine. 

In  every  case  with  cord  injury,  the  patient  should  be  kept  on  a 
water  bed,  with  head  and  foot  extension,  as  in  tuberculosis  of  the 
spine  (p.  609) ;  and  the  utmost  care  should  be  taken  to  prevent  the 
development  of  bed-sores  (p.  62).  The  bladder  should  be  drained 
by  an  inlying  catheter,  if  there  is  retention  of  urine;  and  the  bowels 
generally  have  to  be  moved  by  enemas.  In  most  cases  nothing  further 
can  be  done  than  to  keep  the  patient  comfortable  by  careful  nursing. 
If  life  is  preserved,  efforts  must  be  made  to  maintain  the  nutrition 
of  the  paralyzed  parts  by  massage;  the  development  of  deformities 
from  contractures  (Fig.  244)  should  be  guarded  against,  though  these 
may  be  corrected  later  by  tenotomies;  and  eventually  such  orthopedic 
apparatus  as  is  indicated  should  be  provided,  as  in  this  way  patients 
otherwise  nearly  helpless  may  regain  some  power  of  locomotion. 

The  Quesiion  of  Operation. — In  cases  where,  after  the  first  few  days, 
it  seems  that  the  cord  has  not  been  completely  destroyed — as  evi- 
denced by  persistence  of  reflexes,  early  development  of  spasticity, 
with  shooting  pains,  spasmodic  contractions,  etc. — it  is  justifiable  to 
expose  the  injured  cord  by  laminectomy,  in  the  hope  that  evacuation 
of  blood-clot  (almost  always  extradural)  or  even  the  removal  of 
counter-pressure  on  the  cord  by  the  laminae  and  arches,  may  accel- 
erate the  cure.  But  it  is  in  just  such  cases  as  these  that  a  fair  amount 
of  improvement  may  occur  without  operation;  yet  as  this  cannot  be 
certain  beforehand,  and  as  operation  in  such  carefully  selected  cases 
does  not  increase  the  mortality,  I  think  it  should  be  employed.  Very 
early  operation  (on  the  day  of  injury,  if  possible),  is  proper  in  all  cases 
where  the  spines  and  laminae  have  been  driven  inward  against  the 
cord  by  direct  violence;  since  in  such  cases  it  is  reasonably'  sure  that 
the  displaced  fragments  continue  to  compress  the  cord,  or  that  hema- 
torachis  will  develop  later.  The  same  is  true  of  gunshot  wounds  of 
the  vertebral  column,  in  civil  life,  involving  the  arches;  these  should 
be  treated  by  laminectomy  and  removal  of  displaced  fragments, 
whether  or  not  there  are  cord  symptoms. 

In  other  cases,  with  symptoms  of  complete  transverse  lesion,  in 
most  of  which  the  osseous  lesion  is  collapse  of  the  vertebral  bodies,  it 


INJURIES  OF  THE  SI'INE 


cm 


is  oxtreiiH'ly  j)r(tl);il)l('  tliiit  the  cord  luis  liccii  cruslicd  ])\  tlic  (iisphiccd 
hoiu'  at  the  tinic  of  tlii'  accident,  hut  that  there  is  no  coiitimiiii^  j)res- 
siire  from  the  hone;  and  even  did  such  pressure  exist,  it  is  extremely 
iniprohahle  that  relief  of  the  cord  from  it  would  in  any  way  promote 
recovery  of  function. 

It  is  artjued  hy  some  that  ah  fractures  of  the  vertehrie  should  l)e 
treated  by  immediate  operation,  as  in  the  case  of  fractures  of  tlie 
cranium.  But  the  cases  are  not  similar;  for  in  fractures  of  the  cranium 
we  <lo  not  operate  to  repair  damage  to  the  brain  (which  is  irreparable), 
but  for  the  ])urpose  of  preventing;  infection,  jireventinif  or  relie\ing 
intracranial  ])ressure  (from  efi'used  l)lood  or  displaced  bone),  or  pre- 
venting the  subsequent  development  of  Jacksonian  epilepsy.  In 
the  case  of  vertebral  fractures,  infection  is  very  little  to  be  feared, 
none  of  these  fractures  except  those  from  gunshot  wounds  being  com- 
pound; while  intraspinal  pressure,  in  the  sense  in  which  we  speak 
of  intracranial  pressure,  scarcely  exists,  save  in  the  rare  cases  of 
rapidly  ascending  paralysis  from  hematorachis.  In  spinal  fractures, 
therefore,  operation  should  be  undertaken,  not  to  repair  irreparable 
damage  to  the  cord,  but  as  indicated  above  only  when  it  is  probable 
that  some  extramedullary  lesion  (displaced  bone,  l)lood-clot)  causing 
continuing  pressure  can  be  removed. 


Fig.  637. — -Large  bone  cutting  forceps  for  laminectomv,  with  blades  angled  on 

the  flat. 


Laminectomy. — The  patient  lies  prone.  A  skin-flap  is  turned 
aside,  exposing  the  spinous  processes,  and  the  muscles  are  detached 
by  blunt  dissection  from  the  laminae  of  one  side.  Hemorhage, 
which  is  profuse,  is  readily  controlled  by  pressure  of  hot  gauze. 
Hemostats  are  useless.  The  laminse  of  the  other  side  are  then  cleared. 
When  the  requisite  number  of  arches  (usually  three  or  four)  have 
been  thus  exposed,  the  supraspinous  ligament  connecting  the  lower 
spinous  processes  is  divided,  and  a  large  bone  cutting  forceps,  with 
blades  angled  on  the  flat  (Fig.  037),  is  passed  into  the  opening  and  the 
requisite  number  of  spinous  processes  is  removed  from  below  upward. 
A  crown  trephine  is  then  employed  to  open  the  spinal  canal,  and  the 
opening  thus  made  is  enlarged  by  rongeur  forceps,  biting  aw^ay  the 
laminae  as  far  as  the  articular  processes.  This  method  is  quicker  and 
safer  than  the  use  of  chisel  and  mallet.  When  the  w^ound  is  dry  the 
dura  is  opened  by  a  median  longitudinal  incision,  allowing  the  cerebro- 
spinal fluid  to  escape  slow'ly.    The  cord  is  inspected,  and  spicules  of 


602  SURGERY  OF   THE  SFIXE 

bone,  blood-clot,  etc.,  may  then  be  removed.  Usually  it  is  not  possible 
to  tell  from  the  appearance  of  the  cord  whether  or  not  it  is  the  seat 
of  a  complete  transverse  lesion.  Some  days  or  weeks  after  the  injury 
the  cord,  above  and  below  the  lesion,  may  seem  swollen.  If  the  cord 
is  completely  severed,  attempts  should  be  made  to  suture  it^  with  fine 
chromic  catgut,  introduced  as  mattress  sutures  with  a  fine  curved 
needle.  The  dura  should  not  be  tightly  sutured,  and  it  usually  is  well 
to  leave  a  gauze  wick  for  drainage  down  to  the  dural  surface.  The 
wound  is  then  closed  in  layers. 

Traumatic  Spondylitis  (Kummel,  1891  j. — Under  this  term  is 
described  a  rarefying  osteitis  of  the  vertebrae,  which  develops  after 
severe  contusion  or  fracture,  and  gives  rise  to  a  gradually  increasing 
kyphosis.  Mauclaire  and  Burnier  have  recently  (1912)  collected  one 
hundred  such  cases.  In  spinal  injuries,  long  after-treatment  (plaster 
of  Paris  jackets,  body  braces)  is  necessary  to  prevent  the  development 
of  such  a  deformity.     It  is  treated  as  is  tuberculosis  of  the  spine. 

Osteomyelitis. — Osteomyelitis  of  the  vertebra  is  rare.  Symptoms 
of  general  sepsis  may  obscure  the  local  affection,  so  that  this  may  not 
be  detected  until  abscesses  form,  unless  symptoms  of  compression  of 
the  spinal  roots  or  the  cord  sooner  call  attention  to  the  vertebral 
column.  The  mortality  is  about  60  per  cent.  The  affected  area  should 
be  exposed;  almost  invariably  it  is  the  vertebral  bodies  that  are 
diseased.  The  cervical  spine  is  approached  by  an  incision  posterior 
to  the  sterno-mastoid,  the  thoracic  region  by  an  operation  known  as 
costo-transversectomy  (p.  614),  and  the  lumbar  spine  by  the  retro- 
peritoneal route,  as  in  operations  on  the  kidney.  The  abscess 
is  evacuated,  and  sufficient  bone  is  removed  to  secure  free  drainage. 
If  recovery  ensues,  the  spine  must  be  supported  as  in  convalescence 
from  tuberculosis  of  the  vertebrse. 

Tuberculosis  of  the  Spine;  Pott's  Disease. 2— :\Iore  than  one-third 
of  the  osseous  lesions  of  tuberculosis  are  located  in  the  vertebral 
column.  Children,  from  two  to  ten  years  of  age,  are  affected  oftenest, 
and  the  disease  is  comparatively  rare  in  adults.  Two-thirds  of  the 
cases  begin  in  children  under  five  years  of  age.  The  lesions  are  situated 
almost  exclusively  in  the  vertebral  bodies,  and  aft'ect  the  thoracic 
vertebrae  oftenest  (over  50  per  cent,  of  cases),  and  the  cervical  region 
least  often  (about  15  per  cent.).  Destruction  of  the  vertebral  bodies 
by  caseous  softening,  with  continuance  of  weight-bearing  function, 
explains  the  development  of  various  deformiti*^s.  Cold  abscesses  are 
a  notable  feature  of  the  disease,  forming  its  most  important  complica- 

*  Harte  and  Stewart  (1902j  reported  a  case  of  suture  of  the  spinal  cord  after 
excision  of  the  damaged  area  (three-fourths  of  an  inch  in  extent),  caused  by  bullet 
wound;  there  was  return  of  fair  function  in  the  paralyzed  lower  Umbs.  A.  R. 
Allen  (1911*  has  suggested  immediate  median  longitudinal  section  (2  to  .3  cm.) 
of  the  spinal  cord  in  the  area  believed  to  be  damaged,  on  the  theory  that  para- 
plegia results  from  secondary  compression  from  intramedullary  edema  rather  than 
from  actual  destruction  of  tJtie  cord  tissue  by  the  original  injury. 

^  Paraplegia  resulting  from  this  affection  was  first  carefully  studied  bv  Percival 
Pott  in  1779. 


TUBERCULOSIS  OF   THE  SI'INE  (U\ 

tion.  rarajjlcfjia,  much  less  fre(iiieiit,  and  pr<)l)al)ly  no  mf)re  serious 
in  its  results,  is  the  other  main  complication. 

Symptoms.  The  first  symptoms  to  attract  attention  may  he  mere 
listlessness,  a  desire  to  sit  still  and  to  hold  on  to  the  tables  and  chairs 
in  walking  around  the  room.  Usually  slight  alterations  in  the  gait, 
in  the  manner  of  st()oj)ing,  etc.,  are  observed  very  soon.  The  patient, 
like  \iii\ii:  in  the  presence  of  Samuel,  walks  "delicately,"  fearful  to 
make  any  sudden  movement  lest  the  spine  be  jarred.  The  body  may 
be  held  persistently  to  one  side.  In  trying  to  pick  anything  off  the 
floor,  instead  of  stooping  like  the  normal  child,  by  flexing  the  lumbar 
spine  and  the  i)elvis,  the  j)atient  holds  the  spine  rigid  and  upright, 
and  by  flexing  his  knees  and  hips  brings  his  buttocks  almost  in  contact 
with  the  ground.  In  standing,  the  patient  may  lean  forward  and 
support  his  body  by  resting  his  hands  on  the  thighs;  in  sitting  he  will 
prop  himself  up  on  his  hands;  and  in  disease  of  the  cervical  region 
may  hold  the  chin  in  the  hands  and  turn  the  whole  body  around,  or 
merely  roll  his  eyes,  instead  of  turning  his  head.  At  night  the  child 
is  restless,  and  sleep  may  be  disturbed  by  starting  pains,  with  their 
attendant  night-cries  (p.  479).  "Belly-ache"  often  is  one  of  the 
earliest  complaints,  being  due  to  pain  referred  along  the  intercostal 
nerves.  Pain  occasionally  is  referred  to  the  buttocks  or  the  knees, 
when  the  lumbar  spine  is  diseased. 

Physical  Examination,  thorough  and  systematic,  is  indicated  when- 
ever any  symptoms  point  to  a  possibility  of  spinal  disease.  Have 
all  the  patient's  clothing  removed,  and  let  him  walk  barefoot  to  and 
fro,  studying  the  gait  in  all  aspects.  Let  him  stoop  forward,  flexing 
the  lumbar  spine  and  pelvis,  but  keeping  the  knees  extended,  until 
the  tips  of  the  fingers  touch  the  floor.  Note  any  indications  of 
-discomfort  so  produced,  and  especially  any  break  in  the  normal  con- 
tour of  the  flexed  spine,  which  should  be  one  continuous  curve.  Mus- 
cular spasm,  from  underlying  disease,  W'ill  cause  loss  of  this  rounded 
contour,  and  the  process  of  straightening  up  again  may  be  attended 
})y  jerky  movements.  Then  let  the  patient  sit  on  the  floor  or  on  a  firm 
couch,  and  bend  his  body  well  down  between  his  fully  flexed  thighs, 
so  as  to  flex  the  spine  as  far  as  possible;  and  note  any  irregularity  in 
the  contour.  Then  lay  the  patient  prone,  and  gently  elevate  the  feet 
in  one  hand,  thus  hyper-extending  the  spine  (Fig.  638).  Note  here 
also  any  area  which  lacks  normal  flexibility,  or  which  is  painful. 
Then  raise  the  head  and  shoulders  from  the  bed,  to  test  the  flexibility 
of  the  cervical  and  upper  thoracic  spine  in  the  same  manner. 

When  typical  deformity  once  has  appeared,  diagnosis  is  compara- 
tively easy.  But  earlier  types  of  deformity  should  be  recognized 
when  present.  In  the  cervical  spine,  wry-neck  may  often  be  symp- 
tomatic of  tuberculosis;  in  the  thoracic  region  a  posterior  angular 
curvature  (kyphosis)  is  nearly  pathognomonic;  and  in  the  lumbar 
region  an  exaggerated  lordosis,  wdth  protuberant  abdomen,  may  first 
attract  attention.  Lateral  deviation  of  the  spine  is  seen  chiefly  in 
disease  in  the  dorso-lumbar  or  lumbo-sacral  regions  (Fig.  639)  and  may 


604 


SURGERY  OF  THE  SPINE 


be  due  to  unilateral  spasm  of  the  psoas,  from  incipient  cold  abscess. 
Careless  observation  may  mistake  this  deviation  for  lateral  curvature 


Fig.  638. — Examination  for  rigidity  of  spine  in  Pott's  disease:  the  patient  lies  prone 
and  the  spine  is  hyperextended  by  raising  the  feet.      Orthopaedic  Hospital. 


Fig.  639. — Pott's  disease,  showing  lateral 
deviation  to  left.  Age  thirteen  years.  Dura- 
tion seven  months.     Orthopaedic  Hospital. 


Fig.  640. — Pott's  disease.  Age  seven 
years.  Duration  one  year,  showing 
angular  kyphos.     Orthopaedic  Hospital. 


of  the  spine  (p.  533) ;  but  pain  usually  is  absent  in  the  latter  deformity, 
and  physical  examination  will  detect  neither  tenderness  (abscess?) 
nor  muscular  spasm.    In  cases  where  the  diagnosis  remains  doubtful. 


Tl'liERCULOSlS  OF   TIU'J  SPINE 


005 


tlio  tuhcrciilin  test  (p.  SI)  may  be  tried;  and  under  any  eircimi- 
stances  the  patient  should  he  kept  under  strict  ol)servati()n  until 
further  development  of  symjjtoms  makes  the  diaj^nosis  certain. 

J)rf()riiiify. — Tiiis  requires  further  discussion.  In  the  thoracic  region, 
as  already  noted,  the  deformity  is  characteristically  anf^ular  and  sharj) 
(^'i«,^  (140) ;  as  the  disease  projiresses  the  kyj)hos  hecomes  more  rounded 
[V'lii.  ()41).  In  children  it  is  rather  an  early  development,  and  rarely 
is  absent  after  the  lapse  of  a  few  months.  In  adults,  on  the  other  hancl, 
as  tlie  vertebral  bodies  contain  much  more  calcareous  matter,  the 
disease  may  exist  for  many  months,  sometimes  for  years,  before  any 
noticeable  kyi)lios  dc\el()i)s.     In  low  lumbar  and  sacral  tuberculosis 


Fig.  641 . — Old  Pott 's  disease,  age  six- 
teen years;  duration  since  three  months 
old,  showing  rounded  kyphos.  Ortho- 
pjedic  Hospital. 


Fig.  G42.— Old  Pott's  disease.  Age 
twelve  years;  duration  ten  years.  Show- 
ing stunting  of  patient's  height.  Ortho- 
paedic Hospital. 


the  deformity  at  any  age  is  much  less  conspicuous  than  in  the  thoracic 
and  cervical  regions,  and  may  manifest  itself  only  in  a  stunting  of  the 
patient's  height  (Fig.  ()42).  In  the  cervical  and  lumbar  regions,  where 
lordosis  normally  exists,  the  disease  rarely  causes  more  than  an  obliter- 
ation of  this  anterior  concavity,  rendering  the  affected  spine  straight. 
When  a  kyphos  high  in  the  thoracic  region  is  well  marked,  a  com- 
pensatory liunbar  lordosis  may  develop,  giving  the  patient  a  strutting, 
self-important  air,  while  the  lower  ribs  may  be  depressed  until  they 
rest  on  the  iliac  crests,  markedly  flattening  the  chest  (Fig.  643).  In 
dorso-lumbar  disease,  on  the  contrary,  the  ribs  are  elevated,  marked 
"chicken-breast"  develops,  and  the  outlet  of  the  pelvis  may  be  much 


606 


SURGERY  OF   THE  SPINE 


contracted  antero-posteriorly,  owing  to  the  rotation  of  the  sacrum 
around  a  transverse  axis  (Fig.  641). 

Abscess. — As  the  disease  affects  ahnost  exclusively  the  bodies  of 
the  vertebrae,  any  cold  abscess  that  develops  will  be  found  beneath 
the  anterior  common  ligament.    This  structure  prevents  the  pus  from 
extending   forward,   with    the 
result  that  it  gravitates  along 
various  planes  of  fascia,  and 
comes  to  the  surface  in  rather 
typical     locations.      Only     in 
the   rare   cases   of  disease    of 
the    vertebral    arches    is    the 


Fig.  643. — Cervico-dorsal  Pott's 
disease  with  retro-pharyngeal  abscess. 
Age  twelve  years;  duration  of  disease 
ten  years.  Developed  dyspnea  and 
dysphagia;  and  sinus  formed  on  right 
side  of  neck  posterior  to  the  sterno- 
mastoid  muscle ;  through  this  sinus 
liquid  food  has  been  discharged,  for 
the  last  six  months,  whenever  the 
patient  swallows.  Orthopaedic  Hos- 
pital. 


Fig.  644. — Psoas  abscess  from  Pott's 
disease.  Age  three  years;  Pott's  disease  for 
one  year;  abscess  for  several  months.  Or- 
thopaedic Hospital. 


Fig.  645. — Left  lumbar  abscess  in  Pott's 
disease.  Age  four  years:  Pott's  disease  for 
one  year;  abscess  several  months.  Abscess 
treated  by  operation,  as  advised  in  text. 
No  return  of  abscess,  and  patient  in  good 
health  five  years  after  operation.  Ortho- 
paedic Hospital. 


abscess  apt    to    point  posteriorly,  and   then  usually  in  the  median 


line. 


When  suppuration  occurs  in  disease  of  the  cervical  spine,  it  forms 
a  retro-pharyngeal  abscess;  this  may  cause  dysphagia,  dyspnea,  or 
even  alterations  in  the  voice  if  the  pus  sinks  so  far  as  to  compress  the 


TVHERCVLOSIS  OF   THE  SI'INK 


GOT 


larynx  or  distort  tlie  vjifj;us  nerve  or  its  laryiiji;eal  branches.  As  such 
ail  abscess  increases  in  size,  it  may  rupture  into  tiie  ])harynx  and  cause 
sudden  death  by  suti'ocation ;  or,  as  is  much  more  usual,  may  make  its 
way  to  the  lateral  asjiect  of  the  spine,  and  i)oint  in  the  neck,  usually 
behind  the  sterno-mastoid  muscle  (Fig.  M'A) ;  rarely  it  may  follow  the 
cords  of  the  brachial  i)lexus  into  the  axilla.  In  the  lower  cervical  and 
upper  dorsal  regions,  the  abscess  bulges  into  the  ])osterior  mediastinum, 
and  may  track  along  the  aorta  and  external  iliac  artery  until  it  points 
below  Poui)art's  ligament;  or,  as  is  less  usual,  may  track  outward 
along  the  ribs,  pointing  usually  near  their  angles,  and  simulating  costal 
caries  (p.  731),  which  indeed  may  C()mi)licate  the  spinal  condition. 
In  the  lower  dorsal  and  lumbar  regions  the  pus  usually  passes  beneath 
the  internal  arcuate  ligament  of  the  diaphragm,  invades  the  psoas 
muscle  (jmnis  abscefis),  and  points  in  Scarpa's  triangle  on  the  outer 


ial^> 


Fig.  646. — Early    psoas    contraction    from   left  iliac    abscess.     Age    eleven    years. 
Pott's  disease,  for  four  years.     Abscess  for  eight  months.     Orthopaedic  Hospital. 

side  of  the  femoral  vessels  (Fig.  644).  Usually  such  an  abscess  may  be 
detected  w^hile  still  in  the  iliac  fossa,  when  it  is  known  as  iliac  abscess. 
Sometimes,  instead  of  entering  the  psoas  sheath,  the  pus  passes  beneath 
the  external  arcuate  ligament,  and  points  in  the  lumbar  region  {lum- 
bar abscess),  simulating  a  perinephric  abscess  (Fig.  ()45).  A^ery  occa- 
sionally an  abscess  may  leave  the  pelvis  through  the  sacro-sciatic 
notch  and  point  in  the  buttock  {gluteal  abscess);  and  an  ischio-rectal 
abscess  sometimes  may  be  traced  to  the  spine. 

Diagnosis  of  Abscess. — ^These  various  forms  of  abscess  should  be 
watched  for.  Their  de^Tlopment  may  account  for  contractures 
(especially  of  the  psoas  muscle),  for  an  apparently  inexplicable  exacer- 
bation of  symptoms  (pain,  fever,  disability),  and  very  occasionally 
(when  the  abscess  ruptures  into  the  spinal  canal)  for  suddenly  devel- 
oped paraplegia  or  meningitis. 

Psoas  contraction  is  best  demonstrated  by  placing  the  child  on  its 
back,  with  its  lower  limbs  hanging  over  the  end  of  the  table:  the  normal 


608 


SURGERY  OF   THE  SPIXE 


limb  will  drop  below  the  horizontal,  while  one  with  psoas  contraction 
will  remain  flexed  at  the  hip,  in  spite  of  compensatory  lordosis  (Fig. 
646).  Or,  with  the  child  prone,  the  hip-joints  may  be  tested  for  hyper- 
extension,  as  in  the  examination  for  coxalgia  (p.  -idO).  There  is  little 
difficulty  in  distinguishing  between  coxalgia  and  psoas  contraction 
secondary  to  Pott's  disease;  in  the  former,  the  motions  of  the  hip  are 
limited  in  all  directions,  not  only  in  extension;  and  there  are  no  evi- 
dences of  spinal  disease.  An  iliac  abscess  usually  is  palpable,  a  dis- 
tinct fulness,  which  is  absent  on  the  normal  side,  being  present  along 
the  course  of  the  psoas  muscle.  Intraperitoneal  abscesses,  as  from 
appendicitis,  are  of  much  more  acute  development,  with  symptoms 
of  peritonitis,  and  are  attended  by  leukocytosis. 


Fig.  647. — Pott's  disease  ^"ilh  extreme  angulation,  but  not  SufScient  to  cause  para- 
plegia. Note  that  there  are  present  the  spines  of  fourteen  vetebrse — bodies  of  only  seven ; 
in  other  words,  seven  bodies  have  been  destroyed.  From  a  specimen  in  the  Miitter 
Museum  of  the  College  of  Physicians  of  Philadelphia. 

Paraplegia  from  Pott's  disease,  is  the  effect  of  a  "transverse  myeli- 
tis," or  degeneration  of  the  spinal  cord  from  pressure.  This  pressure 
very  seldom  is  caused  by  bony  deformity  from  extreme  angulation 
(Fig.  647).  Almost  always  the  pressure  is  due  to  tuberculous  granu- 
lation tissue,  usually  extradural  in  situation.  Rarely  the  rupture  of  a 
cold  abscess  into  the  spinal  canal  will  cause  paraplegia,  which  in  these 
circumstances  generally  appears  suddenly.  In  most  cases  the  para- 
plegia is  slow  in  onset,  the  patients  first  becoming  spastic,  and  only 
gradually  losing  the  power  of  locomotion.  Sensation  is  not  often  lost 
entirely,  even  when  motion  is  entirely  aboji.shed;  but  h\'pesthesia  and 
paresthesia  are  frequent.  Complete  flaccid  paralysis  is  rare.  Inter- 
ference with  the  functions  of  the  bladder  and  rectum  occurs  as  in 
fracture  dislocations  of  the  spine. 

Meningitis. — See  p.  579. 


TlliEliVLLOSlS   OF    THE  Sl'lNE 


609 


Prognosis.  The  disease  is  seldom  cured;  in  adults  scarcely  ever. 
It  may  he  arrested  in  childhood,  and  many  u  "hump-hack,"  even  with 
marked  tieformity,  is  enahled  to  lead  for  years  an  active  and  useful 
life.  But  recurrence  of  symptoms  always  is  to  he  feared.  Very  few 
patients  die  as  a  direct  result  of  the  disease,  and  then  mostly  from 
complications,  such  as  tul)erculous  menin<;;itis  or  amyloid  defeneration 
of  the  ^■iscera;  hut  hefore  the  disease  hecomes  latent  ])rol)ahly  one 
patient  out  of  every  three  affected  will  die  from  intercurrent  maladies 
which  would  have  been  survived,  had  not  the  viscera,  particularly 
the  heart  and  lungs,  been  so  distorted  by  the  spinal  deformity.  Neither 
an  unopened  abscess  nor  the  onset  of  paraplegia  seems  to  render  the 
prognosis  more  grave;  but  the  rupture  of  an  abscess,  w'ith  the  secondary 
infection  which  this  entails,  opens  a  door,  as  Calot  says,  through  which 
death  soon  enters. 


Fig.  648. — Extension  from  head  and  Ijoth  feet  for  Pott's  disease.     Orthopaedic 

Hospital. 


Treatment. — To  secure  rest  for  the  diseased  spine  recumbent  treat- 
ment is  almost  indispensable,  and  in  the  acute  stages  is  imperative. 
This  at  once  removes  the  superincumbent  weight.  The  use  of  the 
Bradford  frame  (Fig.  497),  to  which  the  child  is  strapped,  largely  pre- 
vents motion  in  the  spine,  and  immobilit}-  is  further  favored  by  head 
and  foot  extension  (Fig.  648).  Meanwhile,  the  patient  should  be  kept 
in  the  open  air,  night  as  well  as  day  whenever  possible,  and  all  the 
general  measures  useful  in  surgical  tuberculosis  should  be  adopted 
(p.  82).  During  recumbency  it  is  especially  important  to  prevent 
"pointed-toe  deformity,"  which  is  very  apt  to  develop  if  the  foot  is 
39 


610 


SURGERY  OF   THE  SPINE 


unsupported  and  kept  constantly  in  the  equinus  position  by  the  weight 
of  the  bed-clothes.  Careful  trained  nursing  is  indispensable.  A 
nurse  trained  especially  in  this  work  is  desirable  whenever  her  services 
can  be  obtained. 

If  recumbent  treatment  can  be  instituted  before  deformity  develops, 
it  may  be  possible  to  secure  arrest  of  the  disease,  and  to  prevent  the 
occurrence  of  subsequent  deformity.  As  in  the  case  of  tuberculous 
coxitis,  the  only  patients  I  have  seen  whom  I  could  consider  really 
cured  of  the  disease,  without  impairment  of  function,  were  those  in 
whom  such  treatment  was  adopted  before  the  diagnosis  was  entirely 
certain.  When  once  a  kyphos  has  developed  it  is  very  seldom  that 
surgery  can  do  anything  better  than  to  prevent  increase  of  deformity. 
Whitman  prefers  to  treat  early  cases  on  a  frame  which  keeps  the  spine 
hyperextended ;  this  treatment  is  not  applicable  when  fixed  deformity 
already  exists,  and  is  open  to  the  theoretical  objection  that  it  prevents 
collapse  of  the  diseased  vertebral  bodies  and  thus  hinders  ankylosis, 
which  should  be  encouraged,  as  the  only  chance  of  permanent  cure. 
At  one  time  Calot  (1896)  was  an  advocate  of  forcible  correction  of 
any  existing  deformity,  the  patient  being  anesthetized ;  but  a  thorough 

trial  of  the  method  has  caused 
it  to  be  abandoned  not  only  by 
other  surgeons  but  by  Calot 
himself.  It  was  found  that  the 
death  rate  was  markedly  in- 
creased (shock,  traumatic  pneu- 
monia, miliary  tuberculosis, 
spinal  meningitis,  etc.),  and 
that  the  ultimate  cure  of  the 
disease  was  not  accelerated  nor 
the  final  deformity  diminished. 
When  all  symptoms  of  the  disease 
have  been  absent  for  two  or  three 
months  at  least,  ambulatory  treat- 
ment may  be  tried  with  great 
caution,  and  never  without  efficient 
support  to  the  spine.  The  plaster 
jacket,  when  properly  applied,  is 
a  most  efficient  support.  It  may 
be  applied  with  the  patient  re- 
cumbent, or  suspended  by  the 
head  and  shoulders,  the  heels  just  clearing  the  floor  (Fig.  649).  For 
most  cases  of  thoracic  and  lumbar  disease  I  think  the  prone  position 
is  preferable  (Fig.  650) :  the  child  lies  on  a  sling  attached  at  both  ends, 
by  a  bar  and  ratchet,  to  a  Bradford  frame;  the  sling  is  left  just  lax 
enough  to  allow  slight  hyperextension  of  the  spine,  and  is  included  in 
the  plaster  bandages,  being  slipped  out  after  the  plaster  jacket  has 
dried.  With  a  seamless  undershirt  next  the  skin,  and  all  bony  promi- 
nences (pelvis,  kyphos,  axillse)  well  padded  with  saddler's  felt,  such  a 


Fig.  649. — Application  of  plaster  jacket 
with  patient  suspended.  Orthopaedic  Hos- 
pital. 


rUHERCCLOSlS  or   TIIK  SPINE 


Oil 


jacket  may  he  worn  for  several  moiitlis  in  comfort.  The  sur^n;on  slionld 
smell  the  Cast  all  over  every  few  weeks,  and  thus  may  detect  very 
earlv  anv  evidence  of  excoriation.     As  an  additional  ^Miard  aj;ainst 


Fig.  GoO.- 


-Position  for  applying  plaster  jacket  in  Pott's  disease. 
Hospital. 


OrthopiL'dic 


such  an  occurrence,  "scratchers"  may  be  inserted  next  the  skin  before 
the  jacket  is  applied :  these  are  long  pieces  of  bandage,  with  their  pro- 
truding ends  sewed  to  each  other,  and  are  to  be  drawn  up  and  down 
every  day  or  so,  to  keep  the  skin  in  good 
condition.  For  high  dorsal  (above  the 
eighth  thoracic  vertebra)  or  cervical 
disease  the  head  and  neck  must  be  im- 
mobilized also;  and  in  such  cases  it  is 
more  convenient  to  apply  the  jacket 
with  the  patient  suspended.  The  front 
of  the  cast  should  be  cut  away  to 
diminish  its  weight  (Fig.  651). 

Braces. — These  depend  more  on  fix- 
ation (limitation  of  movement)  _  than 
on  support  in  the  sense  of  relief  of 
weight-bearing.  Davis's  brace  (Fig. 
652)  (1898)  takes  a  fixed  point  of  sup- 
port at  the  pelvis  (between  iliac  crests 
and  great  trochanters)  by  means  of  a 
malleable  steel  band;  over  the  iliac 
crests  pass  well-padded  straps,  attached 
behind  and  in  front  to  the  pelvic  band, 
which  eft'ectually  prevent  the  brace 
from  sliding  downward.  Up  from  the 
pelvic  band  on  each  side  of  the  spine 
runs  a  light  steel  bar,  connecting 
through  a  cross-bar  above  with  crutch 
pieces  under  the  axillae;  these  are  sup- 
ported below  by  steels  attached  to  the 
pelvic  band  in  the  mid-axillary  line. 
Nothing  passes  over  the  shoulders,  as  the  object  is  not  to  hang  the 
apparatus  from  the  shoulders,  but  to  support  the  weakened  spine  from 
below.    The  brace  is  thus  fixed  below  at  the  pehis  and  abo^'e  at  the 


Fig.  651. — The  plaster  of  Paris 
jacket  for  upper  dorsal  disease. 
The  jacket  is  trimmed  away  above 
and  below,  and  the  large  abdominal 
window  is  cut  to  allow  of  free 
breathing  and  feeding.  (Cheyne 
and  Burghard.) 


612 


SURGERY  OF   THE  SPINE 


shoulders,  and  presses  forward  on  the  transverse  processes  at  the 
level  of  the  kyphos,  thus  tending  to  hyperextend  the  spine  and 
relie^•e  pressure  on  the  bodies  of  the  vertebrae.  If  the  lesion  is 
above  the  eighth  thoracic  vertebra  it  usually  is  desirable  to  support 
the  head  also,  by  an  attachment   to   the    spinal   uprights.      When 

ambulatory  treatment  is  first  com- 
menced, the  apparatus  should  be  worn 
at  night  as  well  as  during  the  day,  of 
course  being  removed  once  daily  for 
bathing;  but  the  patient  never  should 
he  in  any  other  than  the  recumbent 
yosiiion  except  ivhen  the  sjnnal  support 
is  in  place.  It  should  be  taken  off 
only  after  he  lies  down  and  should  be 
put  on  again  before  he  even  sits  up. 

Some  support  of  this  kind  scarcely 
ever  can  be  dispensed  with;  when  it 
is  abandoned  symptoms  nearly  invari- 
ably return.  This  has  been  demon- 
strated to  be  a  fact  in  so  many  cases 
that  it  is  almost  foolhardy  for  a  sur- 
geon to  tell  a  patient  to  throw  away 
his  braces  and  go  without  support. 
Only  after  many  long  months  of  free- 
dom from  symptoms  is  it  desirable 
to  dispense  with  the  crutch  pieces  of 
the  apparatus,  the  brace  then  con- 
sisting merely  of  a  pelvic  band, 
spinal  uprights,  and  shoulder-straps. 
Such  an  apparatus  gives  practically 
no  support,  but  prevents  dangerous 
degrees  of  movement  in  the  spine. 

Operative  fixation  of  the  spine,  in 
recent  cases  of  Pott's  disease,  has  been 
tj  employed  by  several  surgeons.  Lange 
inserts  two  steel  bars,  one  on  each  side 
of  the  spinous  processes,  and  fastens  them  above  and  below  to  the 
transverse  processes  of  healthy  vertebrae.  Albee  splits  the  spinous 
processes  of  vertebrae  over  the  seat  of  disease  and  of  two  more 
above  and  below,  and  inserts  in  the  cleft  a  sliver  chiselled  off  the 
patient's  tibia;  when  this  grows  fast  firm  ankylosis  is  secured.  Hibbs 
chisels  partly  through  the  spinous  processes  at  their  base,  turns  each 
one  down  until  it  comes  into  contact  wdth  the  base  of  the  spinous 
process  next  below^  and  thus  covers  the  diseased  region  of  the  spine 
with  a  solid  bridge  of  bone.  Of  these  various  measures  I  believe  Albee's 
operation  of  bone  transplantation  is  the  best.  I  have  employed  it 
in  seven  cases,  and  apart  from  one  death  from  pneumonia,  all  the 
patients  have  shown  marked  improvement;  but  in  one  (Fig.  653)  the 


Fig.  (i,jlj.    -liracc    lui    rervical    or 
high  dorsal    Pott's   disease.     Ortho 
psedic  Hospital. 


TUBERCULOSIS  OF   THE  Sl'INE 


013 


transplant  later  hecanio  loosened  at  its  lower  extremity,  and  a  new 
kyplios  developed. 

Treatment  of  Abscess. — -The  general  prineiples  wliieh  should  guide 
surgeons  in  the  treatment  of  tuhereulous  abseesses  and  sinuses  have 
been  diseussed  in  Chapter  XV.  If  reeumbeney  and  immobility  do 
not  cause  retrogression  of  the  abscess,  and  still  more  so  if  it  continues 
to  enlarge,  it  should  be  incised  through  healthy  overlying  tissues, 
should  be  carefully  evacuated,  its  cavity  should  be  thoroughly  wiped 
out  with  iodoform  gauze,  and  the  incision  should  be  tightly  closed  by 
several  layers  of  sutures   (see  Fig.  045).     A  retropharyngeal  abscess 


Fig.  653. — Bone  transplant  in  lumbar  spine.     Epi.scopal  Hospital. 

requires  early  evacuation,  to  prevent  rupture  into  the  pharynx  or 
secondary  infection  from  the  same  source.  In  adults  local  anesthesia 
is  sufficient.  An  incision  is  made,  in  the  lines  of  the  skin,  at  the  pos- 
terior border  of  the  sterno-mastoid  muscle,  and  this  is  defined  and 
drawn  forward;  usually  the  bulging  abscess  is  found  just  beneath  the 
muscle,  and  may  be  opened  by  Hilton's  method  (p.  51).  The  abscess 
wall,  the  muscle,  the  platysma,  and  the  skin,  should  be  sutured  if 
possible  in  separate  layers.  An  abscess  in  the  posterior  mediastinum 
rarely  requires  drainage ;  it  is  exposed  by  excision  of  the  heads  and  necks 
of  the  ribs,  with  the  corresponding  transverse  processes  of  the  diseased 


614  SURGERY  OF   THE  SPINE 

vertebra?  (costo-transversectomy) .  Injury  to  the  intercostal  nerves, 
and  especially  to  the  i)leura  should  be  avoided.  An  iliac  abscess  may 
be  opened  by  a  small  McBurney  muscle-splitting  incision  as  in  appen- 
dicitis (p.  820),  without  fear  of  invading  the  peritoneum  if  the  incision 
is  made  close  to  the  ilium  and  the  dissection  keeps  close  to  iliac  fossa. 
After  evacuation,  and  thorough  wiping  of  the  abscess  walls  with 
iodoform  gauze,  the  wall  of  the  abscess  ca\'ity  and  the  structures  of 
the  abdominal  wall  are  sutured  in  layers.  A  psoas  abscess  does  not 
admit  of  such  secure  closure,  after  evacuation  just  below  Poupart's 
ligament;  but  the  abscess  wall,  the  fascia  lata,  and  the  skin  usually 
can  be  closed  in  separate  layers.  A  lumbar  abscess  is  approached  as 
in  operations  on  the  kidney,  and  usually  the  abscess  wall,  the  lumbar 
fascia,  and  the  skin,  can  be  sutured  separately. 

If  the  abscess  is  giving  no  symptoms,  does  not  tend  to  enlarge,  and 
is  not  so  near  the  skin  as  to  make  probable  the  occurrence  of  secondary 
infection  from  skin  cocci,  it  should  be  left  alone,  and  the  patient  should 
be  treated  as  if  it  did  not  exist.  Constant  watch,  however,  should  be 
kept,  and  proper  treatment  promptly  adopted  whenever  required. 

It  seems  unnecessary  to  add  anything  as  to  the  treatment  of  sinuses 
to  what  was  said  in  Chapter  XV. 

Treatment  of  Contractures. — Often  recumbent  treatment,  with 
weight  extension  applied  first  in  the  axis  of  the  deformity,  will  allow 
contractures  gradually  to  be  overcome.  Occasionally  tenotomies  are 
required  (adductors,  psoas,  rectus  femoris,  tensor  fasciae  femoris,  ham- 
strings, tendo  Achillis,  etc.).  But  in  many  cases  which  have  been 
neglected,  sinuses  exist,  with  secondary  infection;  amyloid  degener- 
ation of  the  viscera  is  present;  and  nothing  remains  but  to  alleviate 
the  patient's  miserable  state  until  death  ends  the  scene  (Fig.  243). 

Treatmetit  of  Paraplegia. — In  almost  every  case  in  childhood  recum- 
bency will  cause  disappearance  of  paraplegia  in  the  course  of  six 
months  or  a  year.  In  such  cases,  then,  it  is  only  after  the  failure  of 
such  treatment  that  the  question  of  operation  need  be  raised.  In 
adults,  also,  recumbency  in  most  cases  will  cause  return  of  power 
within  that  time.  If  after  eight  months  or  a  3'ear  of  recumbent  treat- 
ment in  adults  no  improvement  is  noticed  and  spasticity  still  persists, 
I  think  laminectomy  (p.  601)  should  be  done,  and  the  tuberculous 
granulation  tissue  excised;  the  dura  should  not  be  opened,  as  tuber- 
culous meningitis  probably  would  ensue;  and  it  is  quite  useless,  and 
perhaps  not  always  harmless,  to  curette  away  carious  bone  from  the 
vertebral  bodies.  Only  when  the  paraplegia  is  of  suddeji  onset  do  I 
think  laminectomy  should  be  undertaken  as  an  early  operation. 
In  ordinary  cases  the  symptoms  come  on  very  gradually,  and  the 
ultimate  complete  or  nearly  complete  recovery,  even  after  many 
months  of  complete  abolition  of  the  motor  functions,  is  due  to  this 
very  feature,  as  the  cord  gradually  accustoms  itself  to  the  condition 
of  pressure.  But  when  the  onset  is  sudden  or  very  rapid  (complete 
paraplegia  developing  in  a  few  days  in  a  patient  previously  not  even 
spastic),  the  cord  has  not  the  time  to  so  accustom  itself,  and  there  is 


INFECTIOUS  SPOXDYLITIS  (US 

^Tcat  (lan<jc'r  that  it  may  be  flamafi;e<l  irretrievably  unless  the  pressure 
is  promptly  relieved.  In  eases  with  such  rai)i(l  onset,  as  already'  noted, 
it  is  probable  that  the  cause  is  rupture  of  an  absecss  int(»  the  sjiinal 
canal. 

Other  Forms  of  Infectious  Spondylitis. —  Tyyhoid  Spondylitis 
was  referred  to  at  p.  473.  When  a  patient  has  lain  long  in  bed,  with 
any  wasting  disease,  his  spine  is  apt  to  become  affected  from  static 
strain;  lying  ffat  on  the  back,  the  normal  lumbar  lordosis  may  be 
lost,  and  the  thoracic  kyphosis  may  be  increased.  As  a  consequence, 
when  he  first  assumes  the  erect  i)osture,  or  even  during  convalescence 
in  bed,  complaints  of  stiff'  back  may  be  made.  This  condition  is  not 
very  infrequent  after  long  and  serious  attacks  of  typhoid  fever,  but 
though  it  is  called  colloquially  by  the  name  of  "typhoid  spine,"  it 
should  not  l)e  confused  with  true  typhoid  spondylitis.  The  latter 
condition  is  much  rarer,  and  is  due,  as  suggested  in  1889  by  Gibney, 
and  as  demonstrated  in  1900  by  McCrae,  to  definite  lesions  in  the 
vertebrae,  similar  to  those  occurring  in  the  long  bones  as  a  sequel  to 
typhoid  fever  (p.  425).  Only  a  few  vertebrae  are  involved,  usually 
in  the  lower  thoracic  or  lumbar  region.  The  onset  is  very  acute, 
resembling  the  most  severe  cases  of  Pott's  disease,  with  great  pain, 
which  may  radiate  along  the  spinal  nerves,  and  perhaps  with  cramps 
in  the  extremities.  Any  motion  is  painful.  Sometimes  a  kyphos 
develops.  Treatment  is  the  same  as  for  tuberculous  spondylitis; 
though  ankylosis  may  result,  recovery  usually  is  complete  in  a  few 
months. 

The  spine  maj'  be  affected  also  by  gonococcic  and  pneumococcic 
infection,  as  w^ell  as  by  that  due  to  injfluenza,  tonsillitis,  etc.  The 
symptoms  are  subacute  in  onset,  are  typical  of  an  infectious  as 
distinguished  from  a  dystrophic  process  (p.  452);  and  the  diagnosis 
depends  on  the  recognition  elsewhere  in  the  body  of  the  original 
infective  focus.  According  to  Painter,  the  entire  vertebral  column, 
or  the  greater  part  of  it,  is  affected  at  once,  the  lesions  not  being  con- 
fined to  any  one  region,  as  is  so  frequently  the  case  in  hypertrophic 
arthritis  of  the  spine.  There  is  spinal  rigidity,  but  not  much  deformity, 
unless  this  be  a  slight  lateral  deviation,  or  inclination  to  round 
shoulders.  From  involvement  of  the  costal  articulations,  respiration 
is  hampered.  Treatment  implies  cure  of  the  infecting  focus,  whenever 
this  can  be  discovered,  with  support  to  the  spine  during  the  period 
of  acute  symptoms,  and  counter-irritation,  massage,  and  gymnastics 
at  a  later  date.  The  spine  may  also  be  affected  by  what  were 
described  in  Chapter  XV  as  Subpyemic  and  Cryptogenous  Infections. 
(See  below.) 

Dystrophies  of  the  Vertebral  Column. — These  affections  conform 
more  vr  less  closely  to  the  tw^o  main  types  of  dystrophic  arthritis 
discussed  in  Chapter  X^^  The  term  Spondylitis  Deformans  is  quite 
as  indefinite  as  is  arthritis  deformans,  since  it  may  include  both  types, 
or  be  limited,  as  it  is  by  some,  to  the  hypertrophic  form. 

In  atrophic  spondylitis  the  vertebrae  seldom  if  ever  are  affected  unless 


616 


SURGERY  OF   THE  SPINE 


the  small  peripheral  joints  have  been  attacked  previously;  the  spinal 
changes,  therefore,  occur  merely  as  an  advanced  stage  of  atrophic 
arthritis  as  described  at  p.  452.  Fig.  654  depicts  the  typical  attitude 
assumed  by  these  patients.  Great  care  should  be  exercised  to  exclude 
any  infectious  origin  for  stiffness  of  the  spine,  before  presuming  to 
make  a  diagnosis  of  atrophic  spondylitis.  In  what  have  been  described 
as  the  subpyemic  and  cryptogenous  infections,  the  vertebral  column, 
when  affected,  seldom  presents  the  rounded  kyphosis  (Fig.  654)  which 
characterizes  the  dystrophic  conditions;  usually  it  becomes  abnormally 
straight,  and  the  patient  often  has  been  described  as  having  a  "  poker- 
back."  The  treatment  of  atrophic  spondylitis  has  been  discussed 
suffif^'iently  in  connection  with   atrophic  arthritis   (p.  456). 


Fig.  654. — Atrophic  arthritis  of 
spine ;  age  sixteen  j-ears ;  duration  one 
year.  Fingers,  right  knee,  and  left 
shoulder  are  involved  also.  Ortho- 
paedic Hospital. 


Fig.  65.5. — H\"pertrophic  spondylitis;  in- 
volvement also  of  acetabulum  and  pelvis. 
From  a  specimen  in  the  Miitter  Museum  of 
the  College  of  Physicians  of  Philadelphia. 


In  hypertrophic  spondylitis,  the  spine  may  be  affected  alone,  or  in 
association  with  one  or  more  of  the  larger  joints  of  the  extremities. 
As  in  hypertrophic  arthritis  affecting  such  joints  alone,  so  in  the 
vertebral  disease,  a  history  of  previous  trauma  or  of  actual  static 
strain  usually  may  be  obtained.  As  a  rule  only  a  limited  portion  of  the 
vertebral  column  is  affected,  especially  the  lumbar  region,  frequently 
in   conjunction    with    hypertrophic    arthritis    of    the  sacro-iliac  or 


INTRASPINAL   TUMORS  617 

hip-joint  of  one  side.  The  pathological  changes  closely  resemble  those 
onconntcrcd  in  the  joints  of  the  limbs,  and  exostoses  or  osteophytes 
frcciucntly  may  be  detected  in  skiagraphs.  Early  in  the  disease  there 
is  softening  of  the  vcrtcl)ral  bodies  (rarefying  osteitis),  and  considerable 
<leformity  may  occur,  in  the  form  of  a  more  or  less  rounded  kyphosis. 
As  the  affection  progresses,  however,  the  new-formed  periosteal  out- 
growths tend  to  cover  the  vertebral  bodies  with  a  more  or  less  con- 
tinuous bridge  of  bone,  rendering  the  spine  absolutely  inmiobile  (Fig. 
(555).  Usually  this  bony  coating  is  situated  to  one  or  other  side  of  the 
median  line,  antl  there  may  be  a  corresponding  lateral  deviation  of  the 
spinal  colunni.  If  any  of  the  spinal  nerves  are  compressed  there  may 
be  neuralgic  pains  in  the  parts  supplied,  and  sometimes  there  are 
secondary  muscular  atrophies.  This  complication  was  described  by 
Bechterew  (1892)  as  a  special  type  of  the  disease.  When  one  or 
more  of  the  "root  joints"  {i.  e.,  hip,  shoulder)  of  the  limbs  were 
involved  in  the  hypertrophic  changes,  the  affection  was  considered 
by  j\Iarie  (189S)  a  separate  disease,  and  was  described  by  him  as 
"spondylose  rhizomelique."  In  many  cases  of  hypertrophic  spondy- 
litis the  affection  progresses  so  quietly  that  the  patients  never  apply 
for  treatment,  and  the  deformity  is  discovered  by  incident  or  only 
at  autopsy.  In  others,  pain,  stifl'ness,  and  considerable  disability 
demand  relief.  Treatment  is  to  be  conducted  as  in  cases  where  other 
joints  are  involved  in  hypertrophic  arthritis  (p.  459). 

Intraspinal  Tumors. — Usually  these  are  small,  more  or  less  encapsu- 
lated growths,  springing  from  the  meninges,  and  intradural  in  location 
nearly  as  often  as  extradural.  Very  rarely  has  an  intramedullary 
tumor  been  found.  In  most  of  the  reported  cases  the  tumors  were 
sarcomatous,  but  fibroma,  endothelioma,  echinococcus  cysts,  and  other 
growths  have  been  found;  and  it  is  not  unlikely  that  in  some  of  the 
cases  classed  as  sarcomatous  the  microscopical  diagnosis  was  in  error. 

Symptoms. — Pain  of  a  rheumatic  or  neuralgic  character,  localized 
to  one  limb  or  to  one  of  the  intercostal  nerves,  usually  is  the  first 
symptom.  This  pain  may  subside  under  treatment  but  is  prone  to 
recur,  and  after  a  few  months  or  even  years  is  accompanied  by  a 
numbness  or  heaviness  in  the  affected  extremity.  Though  unilateral 
at  first,  the  symptoms  nearly  invariably  become  bilateral  before 
complete  paralysis  develops.  The  ensuing  paraplegia  conforms  to 
the  ordinary  type  due  to  "pressure  myelitis;"  there  is  spasticity  at 
first,  but  later  complete  flaccidity  develops.  As  physical  signs  of  a 
tumor  (deformity,  rigidity  of  the  spinal  muscles,  tenderness)  usually 
are  absent,  the  diagnosis  depends  largely  on  the  history,  on  the  slowly 
developing  paralysis,  and  on  exclusion  of  other  forms  of  medullary 
compression.  A  neurological  consultation  is  desirable  to  aid  in  deter- 
mining the  spinal  segment  involved.  It  scarcely  ever  is  possible,  to 
determine  before  operation  the  nature  of  the  tumor,  whether  or  not 
it  is  extradural,  or  even  whether  or  not  it  is  intramedullary. 

Treatment. — Immediate  resort  should  be  had  to  laminectomy  when 
once  the  diagnosis  is  reasonably  certain,  as  the  prognosis  is  absolutely 


618  SURGERY  OF  THE  SPINE 

bad  unless  pressure  on  the  cord  is  relieved.  The  usual  mistake,  on 
the  part  of  both  neurologists  and  surgeons,  has  been  to  expect  to  find 
the  tumor  at  too  low  a  level.  Hence  the  surgeon  should  expose  first 
that  region  of  the  cord  which  is  supposed  to  be  affected;  and  if  the 
growth  is  not  found  there,  he  should  search  upward  until  the  cause  of 
compression  is  found.  In  1905  I  collected  for  Ilarte  records  of  92 
operations  for  intraspinal  tumor;  in  only  5  of  these  cases  did  the 
surgeon  fail  to  find  the  tumor,  and  in  three  of  these  it  was  learned 
subsequent!}'  that  it  was  situated  only  a  very  little  higher  than  the 
region  exposed  at  operation.  Elsberg  has  pointed  out  that  in  some 
cases  where  an  intramedullary  or  subpial  tumor  cannot  be  removed 
at  the  primary  operation,  it  will  be  found  to  have  been  spontaneously 
extruded  a  few  days  later. 

The  mortality  of  the  operation  has  been  about  25  to  30  per  cent., 
but  is  less  in  more  recent  times.  Of  those  patients  who  survived 
nearly  60  per  cent,  were  classed  as  cured;  34  per  cent,  as  improved; 
and  in  only  6  per  cent,  was  no  improvement  secured. 

Chronic  Serous  Spinal  Meningitis  usually  is  a  complication  of 
chronic  serous  cerebral  meningitis  (p.  579),  but  ma}'  occur  indepen- 
dently (Krause,  1906),  as  a  localized  collection  of  serous  fluid,  possibly 
the  result  of  a  previous  infection  which  has  caused  adhesion  of  the 
pia  to  the  dura  over  a  limited  area  (Spiller,  1906).  It  produces 
symptoms  closely  resembling  those  of  intraspinal  tumor,  and  the 
treatment  is  the  same. 


CHAPTHR   XIX. 
STTRCEPvY  OF  THE  FACE,  MOUTH,  AND  NECK. 

SURGERY  OF  THE  NOSE. 

Epistaxis  or  Nosebleed  may  occur  spontaneously  or  from  trauma. 
Probably  manv  cases  of  nosebleed  thou^dit  to  be  spontaneous  really 
are  due*  to    slight   trauma,   in    "blowing"   or    "picking"   the    nose. 
Hicrh  arterial  tension,  from  renal  or  cardiac  disease,  is  a  predisposing 
cause     The  patient  should  lie  flat  with  the  head  slightly  elevated, 
and  should  refrain  from  blowing  the  nose.    It  should  not  be  thought 
that  hemorrhage  has  ceased  merely  because  no  blood  runs  out  ot  the 
nostril,  since  the  patient  may  be  swallowing  the  bloo(    as  it  runs 
backward  into  the  pharynx.     Later   such  blood  may   be  vomited. 
Cold  applications  are  efficient  in  checking  the  hemorrhage  in  most 
case«      It  often  is  possible  to  check  bleeding  temporarily  by  raising 
the  arms  above  the  head,  thus  diminishing  the  venous  pressure;  but 
bleeding  mav  recur  when  they  are  lowered.   A  hot  mustard  toot  bath 
may  be  tried.     Applving  a  small  roll  of  gauze  between  the  upper  ip 
and  the  alveolar  process,  in  the  midline,  and  compressing  the  lip 
over  this  pad,  sometimes  will  control   the   bleeding   by  pressure  on 
the  coronarv  vessels  of  the  lip  or  the  arteria  septi  nasi.    In  almost 
every  case  the  bleeding  comes  from  this  artery  as  it  travels  upward 
along  the  cartilaginous  septum  just  within  the  nostril.    By  raising 
the  tip  of  the  nose,  and  with  light  reflected  from  a  head-mirror    it 
often  is  possible  to  see  this  bleeding-point,  especially  it  the  nostril 
is  sprayed   with    cocain    solution    (2   per   cent.)    or   swabbed   with 
adrenalin    (1   to   1000).    These   agents,   or  hydrogen  peroxide,   fre- 
quently are  effective  in  checking  the  hemorrhage.     If  bleeding  per- 
sists, and  as  a  last  resort,  the  tampon  must  be  resorted  to.    It  a  bimp- 
son  splint  (made  of  Bernays's  sponge,  which  when  moistened  swells 
to  eio-ht  times  its  previous  size)  is  available,  it  may  be  inserted  within 
the  nostril,  and  usually  is  very  efficient.    If  bleeding  occurs  from  further 
back  in  the  nostril,  it  may  be  necessary  to  plug  the  posterior  as  well 
as  the  anterior  nares.    This  is  done  by  attaching  a  string  to  the  end 
of  a  soft  rubber  catheter,  and  passing  this  (string  end  first)  along  the 
floor  of  the  nostril  until  the  catheter  emerges  in  the  pharynx;  both 
ends  of  the  string  are  then  pulled  out  through  the  mouth,  and  to  one 
end  is  tied  a  tampon  of  size  sufficient  to  plug  the  posterior  nans  ot  the 
bleeding  side  (Fig.  656).   As  the  catheter  is  withdrawn  from  the  nose 
this  tampon  is  pulled  by  the  string  into  the  mouth,  around  the  pos- 
terior margin  of  the  soft  palate  and  into  the  posterior  nasal  opening. 
The  other  end  of  the  string  is  left  long,  hanging  from  the  mouth,  to 


620 


SURGERY  OF   THE  FACE,   MOUTH,  AND  NECK 


Fig.  656. — Plugging  the  posterior  nares. 


facilitate  withdrawal.  The  anterior  naris  is  then  plugged  from  the 
front.  These  tampons  should  not  be  left  in  place  more  than  twenty- 
four  or  thirty-six  hours,  as  they  are  apt  to  excite  suppuration,  and 

perhaps  maxillary  or  frontal  sinu- 
sitis, or  even  otitis  media.  A  can- 
nula expressly  for  plugging  the 
posterior  nares  was  invented  by 
Bellocq,  and  is  useful  if  at  han(l. 
Foreign  Bodies  in  the  Nose  usu- 
ally may  be  extracted  b}'  fine  for- 
ceps or  scoop,  under  good  illumi- 
nation. If,  however,  the  foreign 
body  lie  not  on  the  floor  of  the 
nose,  nor  anteriorly,  it  will  be 
easier  and  safer  to  dislodge  it  by 
s}Tinging  warm  boric  acid  or  saline 
solution  through  each  nostril  alter- 
nately. 
Acne  Rosacea. — Acne  rosacea  in  its  early  stages,  comes  under 
the  care  of  the  dermatologist;  but  when  through  long  duration  and 
neglect  of  proper  treatment  the  skin  and  subcutaneous  tissues  of  the 
nose  have  become  hypertrophied  (Acne  Hypertrophica,  Rhinophyma), 
then  surgical  treatment  is  necessary  for  a  cure.  The  nose  is  now 
enlarged,  erythematous,  covered  with  dilated  venules  or  arterioles; 
and  nodules  of  various  sizes  and  shapes  make  the  patient  conspicuous 
(Fig.  657).  Treatment:  Frequent  steaming 
of  the  parts,  after  application  of  green  soap 
or  a  soap  poultice,  or  ointments  containing 
sulphur  or  salicylic  acid,  may  somewhat 
improve  the  nutrition  of  the  skin;  but  in 
most  cases  the  over-growths  require  to  be  re- 
moved. Simply  shaving  ofi'  these  excres- 
cences may  suffice,  the  denuded  areas  being 
left  to  heal  by  granulation ;  or  excision  may 
be  done,  and  the  wound  covered  with 
Wolfe  skin  grafts. 

Rhinoplasty.  —  The  formation  of  a  new 
nose,  wholly  or  in  part,  may  be  required  for 
various  reasons.  The  deformity  known  as 
Saddle  Xose   (Fig.   937),  occurring  as   the 

result  of  syphilis,  old  fracture,  or  other  lesion,  may  be  remedied  by 
implanting  beneath  the  skin  a  suitably  shaped  bridge  of  silver  or 
bronze-aluminum.  Subcutaneous  injections  of  paraffin  have  also  been 
employed.  Kolle  uses  paraffin  with  a  melting-point  of  102°  to  115° 
F.,  and  makes  the  injections  (by  means  of  a  special  syringe  with  a 
screw  piston)  with  the  paraffin  cold;  this  obviates  danger  of  embolism. 
No  anesthetic  is  required  if  the  injection  is  made  slowly,  anrl  if  only 
a  small  quantity  is  injected  at  any  one  time. 


Fig.  6.57. — Rhinophyma,  or 
hammer    nose.      (Tillmanns.) 


SURGERY  OF  THE  NOSE 


621 


If  tlic  nose  is  i-omplctely  destroyed  from  injury,  lupus,  syphilis, 
etc.,  a  new  one  may  be  constructed  by  plastic  operations.  In  the 
Indian  inrthnd  of  rhinoplnsfy,  used  by  the  native  surj^eons  of  India 
for  many  centuries,  and  introduced  into  England  in  181G  by  Carpue, 
a  fiaj)  is  taken  from  the  forehead,  and  is  twisted  around  a  pedicle 
wliich  contains  the  angular,  frontal,  and  supraorbital  arteries  of  one  side 
(Fig.  (io8).  The  flap  is  made  a  quarter  of  an  inch  larger  on  all  sides 
than  desired,  as  it  is  sure  to  shrink.  The  edges  of  the  nasal  opening  are 
then  freshened,  and  all  bleeding  is  controlled  by  very  fine  catgut  liga- 
tures. The  frontal  Hap  is  then  rotated  and  is  sutured  in  place  by  tongue 
and  groove  sutures  (Fig.  059).  A  columna  may  be  formed  from  the 
upper  lip,  if  thought  desirable,  after  a  week  or  ten  days,  but  usually  the 
orifice  of  the  new  nose  contracts  so  much  that  it  is  undesirable  to  sub- 
divide it.  The  pedicle  is  not  cut  through  for  about  a  month  after  the 
primary  operation.    The  denuded  frontal  area  may  be  left  to  heal  by 

granulation  or  may  be  covered 
by  Wolfe  grafts.  C.  Nelaton 
and  Ombredonne  (1904)  intro- 
duced a  valuable  modification 
of  the  Indian  method,  in  which 
a  piece  of  the  eighth  costal 
cartilage    is    first    transplanted 


Fig.  658. — Outline  of  frontal  flap  for  rhino- 
plasty by  the  Indian  method. 


Fig.  659. — Tongue  and  groove 
sutures. 


beneath  the  skin  of  the  forehead.  Six  weeks  later  the  flap  con- 
taining this  cartilage  is  cut  and  turned  down  over  the  nose.  A 
cutaneous  lining  for  the  nose  is  also  formed  by  inverting  a  small  flap 
from  the  glabella  and  another  from  each  side  of  the  nose.  The  Italian 
Method  of  lihinojjlasty,  widely  employed  by  Taliacotius  in  the  sixteenth 
century,  consists  in  transferring  a  flap  from  the  arm.  At  the  first 
operation  the  flap  is  marked  out  and  is  par+ially  detached;  when  it 
is  sufficiently  vascularized  and  thickened,  after  the  lapse  of  about  ten 
days,  this  flap  is  stitched  to  the  freshened  edges  of  the  remaining 
nasal  structures,  and  the  arm  and  head  are  securely  bandaged  together. 
A  plaster  of  Paris  dressing  is  desirable.  About  ten  days  or  two  weeks 
later  the  flap  is  cut  away  from  the  arm;  and  a  columna  may  be  formed 
then,  or  sub.sequently. 

Rhinoplasty  has  also  been  done  by  transplanting  a  phalanx  of  the 
finger  or  toe,  or  a  piece  of  costal  cartilage,  into  the  subcutaneous  tissues 
of  the  nose;  but  such  methods  are  applicable  only  when  there  is  suffi- 


(522 


SURCKUY   01'    THE   FACE,   MOITJJ,   AXD   NECK 


ciciit  liealtliy  skin  already  over  the  nose  to  ensure  complete  hnrial 
of  the  transplantcfl  structure.  The  "transplant"  must  he  hrouf^ht 
into  contact  with  hone  denuded  of  periosteum,  so  that  the  Haversian 
systems  extending  from  this  may  permeate  the  transplant  fp.  oiJo). 


Fig.  660. — -Patient  with  destruction  of 
the  nose.  Before  rhinoplasty.  (See  Fig. 
661.) 


^ 

^ 

-V  *^   J 

j^H 

%,M 

Fk;.  661. — Same  patient  after  rhino- 
Ijhisty  hy  the  Indian  method  by  the  late 
Prof.  Ashhurst,  1894.  University  Hos- 
pital. 


SURGERY  OF  THE  CHEEKS. 

Keratosis  Senilis  or  Seborrheic  Patch  has  been  referred  to  in  Chap- 
ter W  as  a  j)recancerous  coiiditioii  of  the  skin.  The  skin  of  the  face 
of  elderly  persons,  especially  those  who  have  been  exposed  much  to 
the  weather,  may  present  a  number  of  slightly  raised,  greasy,  yellow- 
ish-})rown  patches,  due  to  hypertrophy  of  the  epidermal  cells,  and 
accumulation  of  sebaceous  matter  on  the  surface.  If  these  patches 
are  picked  ofi'  ami  a  small  bleeding  erosion  is  revealed,  this  lesion 
probably  is  a  superficial  epithelioma;  if  no  bleeding  occurs  the  lesion 
may  still  be  in  its  precancerous  stage.  Be>'ond  recognizing  this  fact 
ancl  acknowledging  the  possibility  that  proper  treatment  by  a  skilled 
dermatologist  might  i)revent  or  at  least  delay  the  (le\'clopment  of 
epithelioma,  neither  pathologist  nor  clinician  can  go.  Before  there  is 
any  suspicion  of  malignancy,  careful  treatment  of  the  skin  should  be 
adopted.  The  face  should  be  well  steamed  over  a  bucket  of  hot 
water,  at  least  once  daily;  after  thoroughly'  drying,  a  little  salicylic 
acid  ointment  (10  grains  to  the  ounce)  should  be  rubbed  into  the 
seborrheic  patches.  Sometimes  green  soap  (Tinctura  Saponis  \'iridis, 
U.  S.  P.)  should  be  used  instead  of  ordinary  toilet  soap.  D.  W.  Mont- 
gomery, who  has  studied  these  cases  most  carefully,  wipes  ott'  the  skin 
with  glacial  acetic  acid,  and  in  rebellious  cases  uses  trichloracetic 


SURdEh')'  OF   rill-:  CIIKI'JKS 


023 


acid,  alter  turcttiiiK  the  le.su)ii;  then  the  .f-rays  are  eiiiph)\e(L  He 
l)()in'ts  out  that  wlieii  the  cheeks  or  other  portions  of  the  face  are 
widelv  alVected  radical  excision  is  not  to  he  considered  even  if  the 


iy¥—)^-^t^r- 


Y   ^^  yj^k^^Y  Y  Y 


Fig.  662. — Typical  plastic  operations. 

epithehomatons  nature  of  the  lesions  is  recognized;  and  any  flaps 
used  to  repair  defects  left  hy  partial  excision  will  themselves  be  the 
seat  of  these  precancerous  growths,  and  will  in  time  develop  mto 
epithelioma,  causing  an  apparent  local  recurrence.     If  only  one  or 


(i24  SURGERY  OF   THE  FACE,   MOUTH,   AND  NECK 

two  patches  exist,  they  should  be  treated  by  excision,  as  in  fully 
developed  epithelioma. 

Superficial  Epithelioma  or  Rodent  Ulcer  occurs  more  often  on  the 
cheeks  or  forehead  than  any  other  part  of  the  face,  especially  near  the 
ala  nasi,  on  the  lower  eyelid,  or  near  the  angle  of  the  mouth.  Some 
authorities  claim  that  it  owes  its  comparatively  benign  character 
to  the  poverty  of  these  areas  in  lymphatic  vessels.  Its  pathology  and 
clinical  course  have  been  discussed  in  connection  with  tumors,  (p.  123). 
The  question  of  diagnosis  is  important.  It  must  be  distinguished 
from  deep-seated  epithelioma,  lupus,  and  syphilis.  Deep-seated 
epithelioma  rarely  occurs  on  the  face  except  on  the  lower  lip;  it 
may  develop  from  a  seborrheic  patch,  but  it  is  much  more  rapid  in 
growth  than  the  superficial  form  (months  instead  of  years),  and 
invades  the  regional  lymph  nodes.  Lupus  usually  affects  young  adult 
patients  of  scrofulous  diathesis;  it  is  very  rare  in  those  past  middle 
life  in  whom  epithelioma  is  common;  it  almost  always  presents  evi- 
dence of  having  healed  at  some  part,  which  is  rarely  the  case  in  epithe- 
lioma; and  the  typical  apple-jelly  nodules  usually  can  be  discovered 
around  the  periphery  of  the  ulcerated  areas  (p.  263).  The  facial  lesions 
of  syphilis,  especially  ulcerated  gummas,  sometimes  are  mistaken 
for  epithelioma;  but  the  previous  history  of  the  patient,  the  presence 
of  syphilitic  lesions  or  their  traces  elsewhere  in  the  body,  the  cir- 
cinate  or  reniform  shape  of  the  ulcers,  their  greater  depth  and  much 
more  rapid  extension,  as  well  as  the  result  of  antisyphilitic  remedies, 
and  the  presence  of  the  Wasserman  reaction,  will  render  the  correct 
diagnosis  evident.  It  should  not  be  forgotten,  however,  that  malig- 
nant changes  may  develop  in  old  syphilitic  or  lupous  ulcers. 

Treatment. — Treatment  of  rodent  ulcer  consists  in  excision  of  the 
entire  thickness  of  the  cheek  down  to  mucous  membrane  or  bone. 
The  wound  is  then  repaired  by  sliding  flap  as  indicated  in  the  accom- 
panying diagrams  (Fig.  662),  or  by  Wolfe  grafts.  When  it  has  been 
necessary  to  sacrifice  the  mucosa  also,  the  defect  in  the  cheek  may  be 
repaired  by  taking  a  pedicled  flap  from  the  neck  and  adjusting  it  in 
place  with  its  skin  surface  toward  the  cavity  of  the  mouth.  The 
operation  of  repairing  a  defect  in  the  cheek  is  known  as  meloplasty. 

SURGERY  OF  THE  SALIVARY  GLANDS. 

Infectious  Parotitis,  called  also  symptomatic  parotitis,  and  parotid 
bubo,  is  an  acute  bacterial  infection  of  the  parotid  gland  occurring  in 
the  course  of  some  general  infection  (typhoid  fever,  scarlatina,  pyemia, 
etc.).  In  rare  cases  the  submaxillary  or  sublingual  glands  are  similarly 
affected.  In  contradistinction  to  epidemic  parotitis  (mumps),  only 
one  parotid  usually  is  affected,  and  suppuration  is  frequent.  Cases 
of  this  nature  may  also  follow  abdominal  or  other  operations,  but 
rarely,  if  ever,  unless  general  anesthesia  has  been  induced.  In  all 
such  instances,  as  in  typhoid  fever  and  other  wasting  diseases,  there 
is  abundant  opportunity  for  a  direct  ascending  infection  from  the 


SURGERY  OF  TIJK  SALIVARY  GLANDS  02.") 

moiitli  alonfj;  vStcnson's  duct;  and  while  infection  through  tlic  hlood- 
streani  cannot  he  deniech  it  prohahly  is  rare.  In  the  suhstance  oF  the 
parotid  ghuid,  l)et\veen  its  h)hules,  there  are  numerous  minute  lymph 
nodes;  and  it  is  possible  that  some  cases  classed  as  parotitis  really  are 
instances  of  lymphadenitis  of  these  nodes.  Prophylaxis  is  important, 
and  consists  in  measures  to  promote  cleanliness  of  the  mouth  and 
prevent  drying  of  the  nuicosa  around  the  orifice  of  the  })ar()tid  duct. 
Mechanical  injury  of  the  glands  should  he  avoided  during  anesthe- 
tization. 

Treatment.  Local  api)lications  (ice  bag,  painting  with  iodin,  mouth 
washes)  may  be  useful  before  suppuration  occurs.  This  should  be 
treated  i)romptly  by  incision  parallel  with  the  branches  of  the  facial 
nerve.  A  probe  is  then  inserted,  and  an  endeavor  made  to  secure 
drainage  of  all  pockets  of  pus  through  the  one  opening;  but  owing  to 
the  dense  fibrous  stroma  of  the  gland  each  suppurating  lol)ule  may 
ha\e  to  !)c  incised  separately. 

Tuberculosis  sometimes  attacks  the  parotid  lymph  nodes,  but  very 
rarel}^  affects  the  glaiid  itself.  Excision  of  these  nodes  is  difficult 
without  injuring  the  facial  nerve. 

Tumors  of  the  Parotid. — The  peculiarity  of  parotid  tumors  is  that 
they  usually  are  of  the  "mixed"  variety  (p.  106).  This  may  be  due 
to  the  situation  of  the  parotid  in  the  region  of  the  first  branchial  cleft 
of  fetal  life.  These  tumors  are  very  apt  to  contain  cartilage,  with 
areas  of  myxomatous  degeneration;  rareh'  cysts  may  form.  They 
occur  in  young  adults,  and  grow  with  extreme  slowness;  often  no 
change  is  appreciable  from  year  to  year  (Fig.  063).  At  first  they  are 
fairly  well  encapsulated,  but  owing  to  the  def^p  relations  of  portions 
of  the  parotid  gland,  they  appear  to  be  fixed  at  an  early  stage  of 
deAclopment.  Though  the  tumor  may  grow  to  an  immense  size,  the 
facial  nerve  seldom  is  affected;  but  the  lobe  of  the  ear  becomes  dis- 
placed, outward  and  upward.  If  rapid  growth  develops,  as  it  usually 
does  in  time,  malignancy  should  be  suspected  (Fig.  664).  In  very 
advanced  cases,  secondary  enlargement  of  the  cerA'ical  lymph  nodes 
may  occur.  Similar  growths  may  occur  in  the  submaxillary  salivary 
f/hnids,  but  are  much  rarer,  and  seldom  are  distinctly  cartilaginous. 

Treatment. — If  the  patient  is  seen  before  the  tumor  is  large,  and 
before  rapid  growth  has  commenced,  it  often  is  possible  to  enucleate 
the  growth  from  the  substance  of  the  parotid  without  injury  to  the 
facial  nerve  or  Stenson's  duct.  Operation  should  be  urged  before  the 
tumor  grows  very  large.  The  incision  should  be  made  parallel  with 
the  branches  of  the  facial  nerve,  nearly  as  high  as  the  zygoma,  and 
the  knife  should  pass  at  once  to  the  tumor,  with  no  dissection  of  the 
superficial  structures,  as  this  is  apt  to  injure  the  facial  nerve.  The 
growth  is  then  enucleated,  and  the  wound  closed  by  buried  and  super- 
ficial sutures.  In  malignant  cases  wide-sweeping  excision  must  be 
practised  if  any  operation  is  undertaken,  but  an  attempt  should  be 
made  to  preserve  the  facial  nerve  by  exposing  its  main  trunk  before 
it  enters  the  tumor.  Preliminary  ligation  of  the  external  carotid 
40 


626 


SURGERY  OF   THE  FACE,   MOCTII,   AXD   XECK 


artery  often  is  advantageous.  Blunt  dissection  should  be  avoided. 
The  parts  should  be  freely  exposed,  and  nothing  should  be  cut  that 
cannot  be  seen.  The  operation  is  tedious,  difficult,  and  dangerous. 
If  the  tumor  extends  far  into  the  retro-maxillary  fossa  and  appears 
densely  adherent  there,  as  ascertained  by  preliminary  examination 
through  the  mouth,  usually  no  operation  should  be  done.  (See  also 
remarks  on  Excision  (jf  Tumors,  p.  131). 


HIPH 

^B                          ^^^^H 

^^^^Bjj! --.... ^O-  __^^^^^M 

^^^ '  >MH 

Fig.  663.— Mixed  tumor  of  parotid,  age 
forty-two  years;  duration  twenty-two 
years.  Verj-  slow  growth.  Episcopal 
Hospital. 


Fig.  664. — Mixed  tumor  of  parotid 
(sarcomatous;;  twenty-one  years' dura- 
tion. Weight  of  tumor  two  pounds.  Re- 
moved by  the  late  Prof.  Ashhurst,  1896. 
University  Hospital. 


Mikulicz's  Disease  (1892)  is  a  rare  affection  characterizerl  by  pain- 
less, slowly  (le\'eloping,  chronic,  symmetrical  enlargement  of  the 
parotid  and  lachrymal  glands;  sometimes  the  sul)maxillary  and  sub- 
lingual glands  are  involved  also.  In  some  cases  there  is  general  lym- 
phatic involvement  and  enlargement  of  the  spleen.  There  may  be 
fever.  If  such  constitutional  remedies  as  arsenic  and  iodide  of  potash 
are  ineffectual,  extirpation  may  be  justifiable  for  cosmetic  reasons, 
or  to  relieve  pressure  on  neighboring  structures.  The  cause  of  the 
disease  is  unknown. 

Salivary  Fistula. — This  usually  arises  in  the  parotid  gland,  especi- 
ally in  its  main  duct,  as  the  result  of  injury  (operative  or  accidental) 
or  suppuration.  The  secretion  discharges  on  the  cheek  which  is  kept 
constantly  moist,  especially  while  food  is  being  masticated.  The  skin 
may  become  very  much  irritated.  The  mouth  feels  dry.  The  patient 
is  rendered  both  conspicuous  and  miserable. 

Treatment. — If  the  orifice  is  in  front  of  the  masseter  muscle  the 
fistula  is  not  so  difficult  to  cure.  A  cannula  may  be  passed  from  the 
mucous  surface  of  the  cheek  through  the  fistula  on  to  the  cheek  where 
it  makes  two  punctures,  about  one  centimeter  apart;  a  fine  wire  (of 
silver,  iron,  or  bronze-aluminum)  is  then  passed  through  these  two 


SUlUiEUY   OF   Tlll<:  SALIVARY   (iLA.\US 


ivi: 


artificially  iiKuk-  niiicous  orifices  (Fi^'.  ()(').")),  and  is  tied  on  the  mucous 
surface  (Fiji;.  (KiO).  The  edges  of  the  cutaneous  orifice  are  then  fr<'sh- 
ened,  and  it  is  closed  by  suture.  The  parotid  secretions  then  find 
their  \v;i\  aiong  the  wire  to  the  mouth,  and. by  the  time  the  wire  cuts 

out  and  establishes  an  internal 
opening  the  cutaneous  orifice  has 
healed.  If  the  fistula  is  situated 
over  the  masseter  muscle,  at- 
tempts should  be  made  to  con- 
struct a  chaimel  forward  in  the 
cheek  to   its  anterior  edge,  either 


^ ,  ^  ^^^-==^ Mucosa 


Sa/ira/y  duc^ 


Fiii.  005. — Operation  for  salivary  fistula: 
both  ends  of  a  wire  are  conducted  to  the 
mucous  surface  of  the  cheek  through  punc- 
ture made  by  a  cannula. 


C'utaneo/js  opc/ii//^  off/s/ula 


-Skin 


Fig.  666. — Operation  for  .salivary  fis- 
tula: the  wire  is  tied  on  the  mucous  sur- 
face. 


by  establishing  a  seton,  as  in  the  method  just  descrif)ed,  or  by  a 
formal  i)lastic  operation.  Occasionally  partial  excision  of  the  parotid 
gland  will  be  necessary  to  cause  cessation  of  discharge.  If  no  infection 
is  i)resent,  simple  ligation  of  the  main 
(fuct  on  the  central  side  of  the  fistula 
may  result  in  atrophy  of  the  gland. 

Sialo-lithiasis  or  Salivary  Calculus 
is  not  a  very  uncommon  condition.  In 
1908  Bendixen  referred  to  216  cases. 
The  calculous  formation  is  due  to 
bacterial  action  on  the  secretion  of  the 
glands,  as  in  the  pathogenesis  of  biliary 
calculi.  The  calculus  usually  obstructs 
the  excretory  duct,  causing  secondary 
enlargement  of  the  glands,  with  mild 
inflammatory  symptoms.  Occasionall\- 
recurrent  attacks  of  colic  occur.  The 
affection  is  much  more  common  in  the 
submaxillary  than  in  either  the  parotid 
or  sublingual  gland.  Often  the  calcu- 
lus is  palpable  in  the  floor  of  the 
mouth,  just  beneath  the  mucosa. 
Treatment  consists  in  removal  of  the 
stone    by   incision    in  the  floor  of  the 

mouth;  if  the  calculus  is  in  the  body  of  the  gland,  and  especially 
if  there  is  suppuration  or  a  cutaneous  fistula,  it  is  better  to  excise  the 
entire  gland,  by  an  incision  beneath  the  mandible. 

Chronic  Inflammation  may  affect  the  submaxillary  and  sublingual 
salivary  glands.    The  affection  may  simulate  a  neoplasm  in  its  gradual 


Fig.  667. — Chronic  inflammation 
of  submaxillary  and  sublingual  sali- 
vary glands  and  of  submaxillary 
lymph  nodes.     Episcopal  Hospital. 


C)28 


SURGERY  OF   THE  FACE,   MOUTH,   AND  NECK 


onset  and  indolent  course.  Usually  the  glands  are  found  to  contain 
minute  abscesses,  and  there  is  increase  in  the  connective  tissue.  Extir- 
pation is  the  proper  treatment  (Fig.  667). 

SURGERY  OF  THE  EAR. 

Foreign  Bodies. — It  is  necessary  first  to  ascertain  whether  or  not  the 
foreign  body  still  is  present.  In  children  the  history  is  not  always  very 
clear,  and  much  harm  may  be  done  by  incautious  exploration.  If  a 
probe  or  forceps  is  pushed  blindly  along  the  canal,  the  foreign  body 
may  be  driven  further  in.  Under  good  ilhmiination  from  a  head-mirror, 
and  by  drawing  the  pinna  upward  and  backward  to  straighten  the 
external  auditory  canal,  the  surgeon  will  be  able  to  detect  the  presence 
of  a  foreign  body  (Fig.  668).  In  children  the  use  of  an  ear  speculum 
seldom  is  necessary,  but  where  the  canal  is  hairy,  as  in  many  adults, 
this  is  indispensable.  In  most  cases  persistent  syringing  with  warm 
sterile  saline  solution  or  weak  antiseptic  will  be  successful  in  remov- 
ing the  foreign  body;  but  if  this  is  a  pea  or  bean  the  soaking  may 
cause  it  to  swell  up  and  thus  render  its  removal  more  difficult.  For 
such  bodies,  therefore,  and  for  all  others  where  syringing  has  failed, 
delicate  forceps  or  scoop  should  be  employed.  The  same  methods 
should  be  employed  in  cases  of  impacted  cerumen. 


Sy^m^ 


Fig.  668. — Examination  of  external  auditory  canal  bj-  light  reflected  from  a 

head-mirror. 


Furuncle. — Furuncle  of  the  auditory  canal  is  an  exceedingly  painful 
condition  which  requires  prompt  incision.  Even  though  the  sharpest 
knife  is  used,  and  the  incision  made  with  great  delicacy,  the  pain  is 
excruciating,  but  if  the  auriculo-temporal  nerve,  just  in  front  of  the 
tragus,  is  infiltrated  with  a  few  drops  of  a  2  per  cent,  novocain  solution 
complete  anesthesia  is  secured  (Skillern,  1913).  After  opening,  the 
crater  of  the  furuncle  should  be  touched  with  a  drop  of  tincture  of 


SURGERY  or  Till'    EAR 


629 


Fig.   669. — Proper   incision    to 
evacuate  an  othematoma. 


iodiii  or  i)iir(' carholic  acid;  and  a  small  plcdj^'ot  of  cotton  slionld  l)e 
iiitrodnccd,  and  an  ast'ptic  dr('ssin<^  then  l)an(laji;ed  to  the  auricle. 

Hematoma  Auris  or  Othematoma  nsually  is  the  result  of  a  blow. 
It  i.s  not  unconunon  in  patients  in  insane  asylums,  who  can  ^ive  no 
account  of  its  api)earance;  and  on  this  account  it  has  been  thought 
to  have  some  occult  connection  with  un- 
soundness of  mind.  If  it  ever  develops 
spontaneously,  it  probably  is  to  be  attrib- 
uted to  arterio-sclerotic  changes.  The 
eH'used  blood  separates  the  skin  from  the 
cartilage,  usually  over  the  pinna;  and 
unless  proper  treatment  is  instituted  the 
auricle  will  become  conspicuously  deformed 
from  organization  and  cicatrization  of  the 
thrombus.  Tlie  blood  may  be  aspirated 
by  a  hypodermic  needle  in  very  recent 
cases;  but  usually  the  blood  is  semi-clotted, 
and  an  incision  is  necessary.  This  should 
be  made  along  the  helix  (Fig.  GG9),  and 
after  the  blood  is  evacuated  the  skin  should 

be  reapplied  very  carefully  to  the  underlying  cartilage  and  should  lie 
held  against  it  by  accurate  adjustment  of  small  pads  and  a  firm  l)and- 
age.  Unless  this  coaptation  is  very  firm  and  exact,  re-accumulation 
of  blood  will  occur.    After  a  few  days  massage  should  be  employed. 

Prominence  of  the  Auricle,  either  congenital  or  acquired,  may  be 
remedied  by  suitable  plastic  operation.  In  the  usual  congenital  form 
the  pinna  hangs  down  like  a  hood,  and  the  condition  is  named  "  lop- 
ear."  Generally  it  is  sufficient  to  remove  an  ellipse  of  skin  from  the 
posterior  surface  of  the  auricle  and  adjoining  scalp,  and  then  to  suture 
the  ear  against  the  head  and  keep  it  in  place  by  a  firm  bandage.  Some 
such  support  should  be  worn  for  several  weeks.  Occasionally  it  is 
necessary  to  excise  some  of  the  cartilage  of  the  auricle  also. 

Supernumerary  Auricles  are  not  very  rare.  Excision  is  the  proper 
treatment. 

Otitis  Media. — The  middle  ear  is  a  mucous-lined  cavity,  draining 
into  the  pharynx  through  a  long  and  narrow  channel,  the  Eustachian 
tube.  Infection  usually  ascends  from  the  pharynx,  which  often  is 
septic,  especially  if  adenoids  are  present.  Occlusion  of  the  Eustachian 
tube  or  of  either  of  its  orifices  renders  the  middle  ear  a  closed  chamber 
where  microbes  are  prone  to  multiply  and  increase  in  virulence.  The 
middle  ear  in  these  respects  resembles  the  \ermiform  appendix.  In 
cases  of  middle-ear  disease  or  its  complications,  the  services  of  an 
otologist  are  desirable;  but  as  these  cannot  always  be  obtained  in 
emergency,  the  general  surgeon  may  be  called  upon  to  treat  the 
acute  stages  of  such  lesions.  Only  emergency  treatment,  therefore, 
is  considered  in  this  work. 

Catarrhal  inflammation  of  the  middle  ear  frequently  develops  after 
an    attack   of   measles,    pneumonia,    scarlatina,    or   other   infectious 


030  SURGERY  OF   THE  FACE,   MOUTH,   AND  NECK 

flisease.  It  is  accoinpaiiicHl  by  ear-ache,  sli<,flit  deafness,  a  sense  of 
fulness  in  the  ear,  sH<i;ht  feverishness,  and  i)r()})ahly  some  dxsjjha^ia. 
Ins])eeti()n  of  the  drum  membrane,  with  reflected  hj,dit,  throu<:;h  a 
speculum,  shows  it  reddened  and  swollen,  and  sometimes  buljjiiif;, 
especially  in  tlie  posterior  part.  By  moving  the  })atient's  head  back 
and  forth  it  may  be  ])ossible  to  see  the  undulation  of  fluid  throu^rh  the 
semi-transparent  drum  membrane.  Later  the  membrane  becomes 
opacpie. 

In  acute  purulent  inflammation  of  the  middle  ear  the  symptoms 
are  the  same  in  kind  though  usually  more  severe  in  degree.  The 
afl'ection  usually  is  purulent  from  the  first,  and  does  not  follow 
catarrhal  inflammation.  In  children  the  afi'ection  may  run  its  course 
almost  without  pain,  although  pressure  on  the  tragus  usually  is  painful, 
as  the  bony  canal  is  still  incomplete,  and  movements  of  the  auricle  are 
communicated  to  the  middle  ear.  Often  only  a  sudden  rise  of  tempera- 
ture will  show  any  deviation  from  the  normal.  I'his  is  so  frequently 
the  case  in  children  that  any  sudden  rise  of  temperature  during  con- 
valescence from  the  exanthemas,  influenza,  bronchitis,  etc.,  demands 
examination  of  the  ears.  If  such  examination  is  neglected,  the  first 
thing  to  attract  attention  to  the  ear  may  be  the  discharge  of  pus 
following  spontaneous  perforation  of  the  drum  membrane. 

Treatment. — Simple  "ear-ache,"  which  may  be  due  to  referred 
pain  from  pharyngeal  or  dental  affections,  or  may  be  a  mild  form  of 
catarrhal  otitis  media,  usually  may  be  relieved  b>'  instillation  into 
the  external  auditory  canal  of  a  few  drops  of  hot  water.  This  is  quite 
efficient  as  hot  laudanum  or  other  drug.  It  is  the  heat  rather  than  the 
drug  that  is  effective.  If  there  is  evidence  of  accumulation  of  fluid 
within  the  tympanic  cavity,  especially  if  there  is  any  bulging  of  the 
membrane,  this  should  be  incised  (myringotomy) :  after  suitable  clean.s- 
ing  of  the  canal  by  dilute  hydrogen  peroxide  and  aseptic  syringing, 
the  incision  is  macle  in  a  cur^•ed  line  around  the  entire  posterior  cir- 
cumference of  the  drum  membrane,  thus  forming  a  flap,  which  allows 
much  more  free  and  prolonged  drainage  than  a  mere  puncture.  The 
point  of  the  knife  should  not  do  more  than  penetrate  the  membrane, 
as  the  tympanic  cavity  may  be  very  shallow\  The  ear  is  drained  by 
a  small  strip  of  gauze  extending  just  as  far  as  the  drum  membrane; 
this  should  be  renewed  as  often  as  it  becomes  soaked  with  discharge — 
several  times  an  hour  if  necessary.  Several  times  daily,  not  oftener 
than  every  two  or  three  hours,  the  canal  should  be  irrigated 
gently  with  a  weak  antiseptic  solution.  Heat  to  the  mastoid  will 
be  grateful,  and  sedatives  may  be  requisite  to  allay  the  pain.  The 
patient  must  be  confined  to  bed  for  several  days.  The  nasopharynx, 
whence  the  infection  usually  has  come,  should  receive  appropriate 
treatment. 

Acute  Mastoiditis. — Invasion  of  the  mastoid  cells,  by  extension 
of  infiammation  from  the  middle  ear  through  the  aditus  and  the 
antrum,  occurs  in  many  cases  of  acute  purulent  otitis  media.  Prom])t 
treatment   of    the'  middle-ear  disease  by   myringotomx'   will   permit 


SlfRGERY  OF   THE  EAR 


(VM 


rec()\('r>'  in  many  cases  witliDUt  pennaiiciit  daiiiaf^c  to  the  aiitriim 
or  mastoid.  It'  the  discharjfo  of  j)us  jxTsists  Inii^f,  and  is  profuse,  in 
s|)ite  of  pro|)er  conservative  treatment  of  the  middle  ear,  it  usually 
indicates  that  there  is  involvement  of  the  mastoid  cells.  This  is  a 
chronic  condition,  however,  and  does  not  concern  us  here.  Not  infre- 
(piently,  shortly  hefore  s\inj)tonis  of  nriitr  mastoiditis  a])pear,  an  ear 
which  had  i)cen  "running'"  for  months  or  years  suddenly  ceases  to 
discharge.  Tlie  patient  has  pain  in  and  l)ehind  the  ear;  there  is  fever, 
perha|)s  chilliness  or  an  actual  chill;  lieadache  aiui  general  malaise. 
The  mastoid  is  tender,  not  only  at  its 
tip,  as  sometiines  occurs  in  cases  of 
simple  otitis  media,  hut  especially  over 
the  emissary  vein  and  the  antrum;  and 
in  some  cases  there  is  e\idence  of  peri- 
osteitis.  In  children  j)us  often  makes  its 
way  outward  alon<^  the  petro-mastoid 
suture,  bulges  beneath  the  periosteum, 
and  causes  the  auricle  to  stand  away 
from  the  head  in  a  very  characteristic 
manner  (Fig.  ()7()).  In  rarer  cases  an 
abscess  forms  deep  in  the  neck  beneath 
the  sterno-mastoid  muscle  (BezoIcVs 
abscess).  In  adults  movement  of  the 
auricle  is  not  painful;  this  is  an  impor- 
tant differential  sign  from  furunculosis 
of  the  external  auditory  meatus.  But 
in  children,  in  whom  the  bony  canal  is 

less  well  developed,  mo^■ement  of  the  auricle  is  communicated  to  the 
middle  ear  and  hence  usually  causes  pain. 

Diagnosis. — This  rests  on  the  previous  history  of  the  case,  namely, 
onset  of  ear  trouble  usually  in  convalescence  from  an  acute  infectious 
disease;  on  the  existence,  past  or  present,  of  chronic  otitis  media; 
and  on  ])hysical  examination  of  the  ear,  showing  mastoid  tenderness, 
redness,  and  edema,  perhaps  with  protrusion  of  the  auricle. 

Prognosis. — If  the  infecting  organism  is  the  staphylococcus  or  even 
the  pneiunococcus,  recovery  without  operative  treatment  (other 
than  myringotomy)  may  occur  in  a  fair  proportion  of  cases.  Where 
the  streptococcus  or  the  Bacillus  mucosus  capsulatus  is  found,  bone 
destruction  is  apt  to  be  much  greater,  and  very  seldom  can  operation 
be  avoided. 

Treatment. — In  cases  which  develop  soon  or  immediately  after  the 
first  appearance  of  an  otitis  media,  operation  on  the  mastoid  may  be 
delayed  one  or  two  days,  to  ascertain  what  effect  the  myringotomy 
will  have  on  the  mastoid  symptoms.  But  if  the  B.  mucosus  capsu- 
latus is  found  in  the  discharge  from  the  middle  ear  no  delay  in  operating 
should  be  permitted;  operation  should  not  be  postponed  even  until  the 
next  day.  When  the  streptococcus  is  fountl  delay  never  should  be 
longer    than    one   week,   even   when   clear    signs    of    mastoiditis   are 


I  II,.  G7lJ.  —  Mastoid  abscc.-^s 
(left;  pointing  through  petro- 
mastoid  suture.  Age  three  and 
a  half  years.  (Dr.  Gibbs'scase.) 
Episcopal  Hospital. 


632  SURGERY  OF   THE  FACE,   MOUTH,   AND  NECK 

lacking.  Prom])t  drainage  of  the  infected  bone  is  demanded.  There 
is  great  risk  of  sinus  tlironibosis  (p.  577)  or  l)rain  al)scess  (p.  579)  if 
there  is  delay,  especially  in  cases  occurring  as  exacerbations  of  long 
standing  middle-ear  disease  with   inefficient  drainage. 

Operation  for  ^ic7itc  Mastoiditis. — An  incision  is  made  from  the  tip 
of  the  mastoid  process  upward,  parallel  with  and  about  5  mm.  post- 
erior to  the  attachment  of  the  auricle,  for  a  distance  of  two  or  three 
inches.  This  incision  passes  directly  to  the  bone,  but  as  in  children 
the  bone  is  very  soft,  great  care  should  be  taken  not  to  cut  too  deeply. 
If  the  posterior  auricular  artery  is  di\ide(l,  it  should  be  clamped  and 
ligated  at  once.  The  periosteum  is  then  separated  from  the  bone 
throughout  the  length  of  the  incision,  for  a  space  of  nearly  an  inch 
in  width,  exposing  the  posterior  wall  of  the  external  auditory  meatus, 
and  the  siijjranicatal  spine  of   Henle.     The  sternomastoid  muscle  is 


Fia.  671. — Macewen's  triangle,  outlined  on  the  skull;  and  the  suprameatal 
spine  of  Henle. 

then  detached  from  the  mastoid  tip,  cutting  it  close  to  the  bone.  If 
more  room  is  required  at  any  stage  of  the  operation  an  incision  is 
carried  backward  from  the  centre  of  the  post-auricular  incision,  and 
the  two  triangular  flaps  so  formed  are  elevated  from  the  bone.  The 
surgeon  next  identifies  the  suprameatal  triangle  (Macewen,  1893),  which 
lies  above  and  behind  the  external  auditory  meatus;  it  is  bounded 
in  front  by  the  bony  wall  of  this  canal  and  the  suprameatal  spine, 
above  by  the  posterior  root  of  the  zygoma,  and  posteriorly  by  a  line 
joining  these  two  (Fig.  071).  This  triangle  is  the  guide  to  the  situa- 
tion of  the  antrum,  over  which  it  lies.  In  children  the  antrum  lies 
at  a  higher  level  than  in  adults,  in  whom  it  is  more  behind  than  above 
the  meatus.  Usually  the  bone  directly  covering  the  antrum  is  per- 
forated by  minute  venous  channels,  and  the  antrum  may  be  located  in 
this  way.  The  antrum  may  be  opened  first  (Fig.  672),  as  advised 
by  Macewen;  or  the  surgeon  may  first  remove  the  cortex  overlying 


si'RCEin'  or  THE  ear 


(i.33 


tlio  niiistoid  cells,  iVoiii  the  tip  of  tlic  mastoid  up  to  the  iiiitrimi.  If 
a  dental  (.'ii,i,niu'  is  a\ailal)k',  a  rotary  hiirr  is  a  wry  satisfactory  iiistru- 
nu'iit.  I  siially,  however,  a  ^ouf^o  and  mallet  are  used  to  remove  the 
cortex,  and  then  the  pneumatic  cells  are  excavated  by  a  bone  curette 
or  fine  ^ou^e  forceps.  In  youn^  children  a  stronj^  curette  will  remove 
the  cortex  also.  The  instruments  should  be  made  to  cut  from  within 
outward,  unless  the  parts  are  fully  exj)osed.  The  entire  mastoid, 
includiuff  its  tip,  should  be  removed;  and  in  most  cases  all  the  pneu- 
matic cells  which  are  accessi})le,  wherever  situated,  should  be  removed, 
inclu(lin<i;  any  in  the  posterior  zygomatic  root.  As  the  pneumatic 
cells  may  extend  along  the  petrous  portion  of  the  tcm])oral  bone  even 
to  its  apex,  it  manifestly  is  impossible  to  remove  all  in  every  case, 
and  in  cases  wlicr(>  the  patient  is  extremely  septic  it  undoubtedly  is 
better  merely  to  secure  free  drainage,  and  to  leave  the  C()ni])lcti()n  of 


Fig.  672. — Operation  upon  the  mastoid 
antrum.  The  antrum  (a)  has  been  laid 
open  and  gouged  out,  and  the  bridge  of 
bone  (b)  between  it  and  the  external  audi- 
tory meatus  is  seen.  (Cheyue  and  Burg- 
hard.) 


Fig.  673. — Operation  upon  the  mas- 
toid antrum.  A  bent  probe  has  been 
introduced  from  the  antrum  to  the 
middle  ear.     (Cheyne  and  Burghard.) 


a  radical  operation  for  another  occasion.  But  in  every  case,  without 
exception,  it  is  necessary  to  open  the  antrum,  and  thus  accomplish 
the  purpose  of  the  operation,  the  securing  of  free  drainage  of  this  region 
of  the  middle  ear  through  the  mastoid.  As  the  bone  is  being  removed 
it  should  be  repeatedly  examined  by  the  probe;  the  antrum  is  recog- 
nized by  the  probe  passing  first  upward,  then  forward  and  inward 
into  the  middle  ear  (Fig.  673).  A  probe  introduced  into  the  middle 
ear  through  tlie  jjerforated  tympanic  membrane  may  be  an  aid  in 
locating  the  antrum. 

The  structures  in  most  danger  of  injury  are  the  sigmoid  siinis, 
the  facial  nerve,  and  the  horizontal  semicircular  canal.  If  a  gouge  is 
used,  cutting  from  without  inward,  it  should  be  bevelled  on  its 
convex  surface,  and  should  be  applied  very  obliquely  to  the 
surface  of  the  skull,  so  that  if  the  lateral  sinus  is  exposed  it  will  be 
pushed  ahead  of  the  gouge  and  not  wounded.     Usually  the  inner 


634  SURGERY  OF   THE  FACE,   MOVTIl.   AM)  XECK 

(vitreous)  layer  of  the  mastoid  process,  which  separates  the  sinus  from 
the  pneumatic  cells,  may  be  recognized  when  the  latter  have  been 
cleared  away.  If  there  is  reason  to  suspect  sinus  thrombosis,  this 
bone  must  be  removed  also,  and  the  sinus  treated  as  recommended  at 
page  577.  The  facial  ner\e  is  in  most  danger  as  it  passes  outward  and 
slightly  backward  beneath  the  floor  of  the  (iditus  ad  antrum.  The 
horizontal  semicircular  canal  projects  into  the  median  wall  of  the  aditus 
ad  (iiitniDi.  The  curette  should  not  be  used  in  either  of  these  situations. 
The  roof  of  the  antrum  and  the  aditus  is  very  thin,  and  the  middle 
cratiial fossa  lies  directly  above  it;  but  this  will  not  be  opened  if  no  lione 
is  removed  above  the  line  of  the  temporal  ridge  (continuation  of  the 
posterior  root  of  the  zygoma).  The  condition  of  the  bone  forming 
the  tegmen  antri  should  be  ascertained  by  very  gentle  probing.  If 
it  is  carious  or  perforated  it  should  be  removed  gently  with  curette 
or  gouge  forceps,  since  there  may  be  an  extradural  abscess  above 
it  requiring  drainage.  The  treatment  of  intracranial  abscess  has 
been  considered  at  page  581. 

When  the  operation  is  concluded  the  cavity  is  lightly  tamjjoned 
with  iodoform  gauze,  and  the  skin  incision  closed  except  at  the  lower 
angle.  An  aseptic  dressing  is  applied,  and  the  head  bandaged.  The 
after-treatment  requires  great  care.  The  patient  is  confined  to  bed 
for  several  days;  and  the  wound  is  dressed  on  the  third  day.  and  the 
gauze  packing  renewed.  Not  until  firm  granulations  have  formed 
should  syringing  be  employed,  but  the  sinus  left  by  the  operation  and 
the  external  auditory  meatus  may  be  gently  cleansed  with  pledgets 
of  absorbent  cotton  moistened  with  dilute  hydrogen  peroxide.  The 
subsequent  care  is  that  for  any  granulating  surface.  In  the  most 
favorable  cases  healing  is  complete  in  from  four  to  six  weeks. 


SURGERY  OF  THE  LIPS  AND  PALATE. 

Hare-lip  and  Cleft  Palate. — These,  which  are  conveniently  con- 
sidered together,  are  the  most  frequent  congenital  deformities  of  the 
face.  They  are  best  understood  by  reference  to  the  accompanying 
diagram  (Fig.  ()74),  which  represents  an  embryo  of  three  weeks.  The 
fronto-nasal  process  (a)  is  descending  between  the  maxillary  ])rocesses 
(b  h).  The  eyes  are  represented  by  c  r.  and  the  mandibular 
processes  by  d  d.  Failure  of  the  embryonal  maxillary  processes  to 
coalesce  in  the  median  line  leaves  a  fissure  of  varying  extent  in  the 
upper  lip  and  palate. 

//  the  fissure  is  single,  it  does  nqt  occupy  the  median  line  but  cor- 
responds to  the  line  of  junction  between  the  intermaxillary  bone 
(fronto-nasal  process)  and  the  superior  maxilla.  But  a  cleft  of  the  soft 
palate,  antl  one  of  the  back  part  of  the  hard  jialate  is  in  the  median 
line,  as  the  frontal  process  (intermaxillary  bonej  does  not  extend 
backward  so  far.  In  a  complete  double  cleft  of  the  palate,  therefore, 
the  fissure  is  Y-shaped,  double  in  front,  and  single  behind. 


Srix'af'Jh'y   OF   THE  Lll'S   AM)   I'ALATE 


035 


//'  fin-  fi.s.snrc  is  double,  the  iiitennaxillary  Ijoiic  usually  projofts  in 
front  of  the  lip  ( Fij;.  (17")),  and  the  fissures  may  inxoKc  hotli  |)alat('  and 
lij).  or  citluT  one  to  the  exclusion  of  the  other.  As  a  f^eneral  rule  it  may 
he  said  that  cleft  i)alate  without  hare-lip  is  very  rare,  while  hare-lip 
without  accompanying  deformity  of  the  palate  is  fairl\'  conunon. 

The  projwr  aijc  for  opcnifidii  always  has  heen  a  matter  of  discussion. 
As  the  existence  of  cleft  i)alate  is  a  more  serious  disability  than  that 

of  hare-lij),  it  should  take  |)recedence 
in  matter  of  operation.  Where  there 
is  no  deformity  of  the  palate,  the  best 
time  for  ojxTation  on  the  lip  is  from 
six  weeks  to  three  months  after  birth. 
Those  surgeons  who  have  most  experi- 
ence with  these  deformities  have  come 
to  share  the  opinion  of  Brophy,  of 
Chicago,  who  since  1900  has  been  urg- 
ing that  the  best  age  for  operation  on 
the  palate  is  between  the  age  of  two 
weeks  and  three  months.  When  not 
contraindicated,  the  hare-lip  may  be 
repaired  at  the  same  time.  But  the 
palate  should  be  repaired  before  the 
lip.  Infants  with  cleft  palate  and  hare-lip  usually  are  stronger  soon 
after  birth  than  subsequently,  owing  to  the  difficulty  of  suckling 
them.  In  such  young  patients  operation  may  be  done  without  an 
anesthetic  if  absolutely  necessary;  they  have  no  apprehension  of 
pain  or  suffering  to  come,  nor  any  memory  of  it  after  it  has  past. 


Fi(i.  r)74. — The  hoatl  of  an  cni- 
hryo  of  three  weeks.       (See  text.) 


Fig.  675. — Double  hare-lip  and 
cleft  palate.  Age  two  days. 
Note  the  projecting  intermaxil- 
lary bone.    Orthopaedic  Hospital. 


Fui.  676. — Hanging  head  position,  for  operations 
on  the  palate. 


But  in  most  cases  there  is  no  contraindication  to  the  use  of  ether  or 
chloroform.  Ether  is  preferable  in  older  children  and  in  adults.  It 
is  administered  in  the  "hanging  head"  position  (E.  Rose,  1874), 
and  the  surgeon  stands  at  the  patient's  head,  thus  getting  a  good 
view  of  the  inverted  palate  (Fig.  ()7()).  The  use  of  a  mouth  tube  for 
anesthetization  is  a  great  convenience. 

Hare-lip. — Sitigle  hare-lij)  varies  from  a  mere  notch  to  a  fissure 
extendi;ig  into  the  nostril,  and  perhaps  continuous  with  a  unilateral 


036 


SURGERY  OF   THE  FACE,   MOUTH,   AND  NECK 


cleft  of  the  palate.    The  principle  of  the  operation  consists  in  freshen- 
ing the  edges  of  the  fissure  and  suturing  them  together.    The  lip  is 


Fig.  677 


l"iG.  07S 


Figs.  677  and  678. — Nelaton'.s  method  for  iiifomplete  single  hare-lip. 

first  freely  separated  from  the  u])per  jaw,  by  (li\iding  the  frenum  or 
other   adhesions.      Bleeding   should   be  controlled  promptly  by  mos- 


FiG.  679 


Fig.  680 


Figs.  679  and  680. — Malgaignc's  method  for  complete  single  hare-lip. 

quito  hemostats.     If  there  is  a  mere  notch  in  the  lip  it  is  sufficient 
to  employ  Xelaton's  operation  (Figs.  ()77  and  ()7S) ;  usually,  however, 

it  is  better  to  pare  both  edges  of  the 
fissure  in  a  line  slightly  concave  toward 
the  median  line.  The  knife  is  entered  at 
the  apex  of  the  fissure  for  denuding  each 
margin;  and  care  is  taken  that  these 
incisions  unite  above  the  apex  of  the 
fissure  and  that  enough  of  each  flap  is 
left  at  the  free  border  of  the  lip  to  ensure 
a  projection  on  the  vermilion  border  when 
the  edges  are  vmited  (Figs.  079  and  080; 
Malgaigne's  operation,  1844) ;  if  the  ver- 
milion border  is  sutured  flush,  the  con- 
traction of  the  cicatrix  soon  will  cause  a 
depression.  Interrupted  sutures  of  fine 
silkworm  gut  or  horsehair  are  used.  They  are  introduced  from  the 
cutaneous  surface  down  to  but  not  tlirough  the  mucous  membrane. 


Fig.  681. — Hare-lip  pins  in  use 
with  twisted  suture;  points  of  pins 
cut  off  and  wrapped  in  adhesive 
plaster. 


SUltGERY   OF    THE   LJl'S   AM)   rALATE 


y'uu 


Or  hare-lip  pins  and  a  twistrd  suture  may  be  used  for  the  main  sup- 
j)()rt,  with  superlicial  iuterrupli-d  sutures  to  secure  accurate  coaj^tation 


Fiti.  (582 


Fiu.  083 


Figs.  082  and  083. — Owen's  nietliod  for  coniijlete  siiiKlc  liarc-lip. 

(Fig.  (iSl).     If  the  fissure  is  hirger  than  a  mere  notcli,  it  is  better  to 
adopt   some  form  of  phistic  operation,  as  indicated  in  I'igs.  ()S2  and 


Fig.  084 


Fig.  68.5 


Figs.  684  and  685. — Method  of  improving  the  shaj  e  of  tlie  iK-.stril.     (Stone.) 


(i83.      To  improve  the  nostril,  a  wire  suture  shotted  at  both  ends  may 
be  passed  as  indicated  in  Figs.  684  and  685. 


Fig.  086 


Fig.  687 


Fig.s.  086  and  687. — Hagedorn's  method  for  double  hare-lip. 

Double  Hare-lip. — The  operation  here  is  the  same  as  in  cases  of 
single  hare-lip,  the  margins  of  each  fissure  being  freshened  and  sutured 
separately;  but  often  it  is  well  to  bring  a  small  flap  from  the  larger  side 
across  beneath  the  intermaxillary  bone,  to  form  the  prolabium;  and 


08S 


SURGERY  OF   THE  FACE.   MOrril,   AXD  XECK 


if  there  is  sufficient  tissue  a  second  still  smaller  flap  from  the  other 
side  may  be  introduced  between  this  flap  anrl  the  intermaxillary  bone 
If  the  intermaxillary  bone  protrudes  and  cannot  be  pushed  back  intf) 
place  even  by  division  of  its  attachment  to  the  septum,  it  may  be 
excised;  but  as  it  bears  the  central  incis(jr  teeth  this  should  not  be 
done  recklessly. 

After  the  operation  the  parts  are  painterl  with  Whitehead's  varnish,' 
and  a  long  strip  of  adhesive  plaster  is  applied  from  one  ear  to  the  other 
across  the  upper  lip.  The  baby  should  be  put  to  the  breast  or  fed 
from  a  bottle  as  soon  as  convenient,  as  the  motions  involved  in  sucking 
tend  to  lessen  tension  on  the  sutures.  Minute  doses  of  paregoric  may 
be  reqiiirefl  to  check  crying.  Everv  alternate  stitch  may  be  removed 
about  the  fourth  or  si.xth  day,  and  the  remainder  from  the  eighth  to 
the  tenth  day. 

Cleft  Palate. — If  the  operation  is  done  in  early  infancy  the  max- 
illar\"  bone-  are  cartilaginous,  and  may  be  brought  into  apposition 
by  moderate  pressure.  This  permits  suture  of  the  vivified  margins 
of  the  cleft  without  tension,  and  restoration  of  normal  relaticms  of 
the  parts  concerned  in  phonation  before  the  child  begins  to  talk. 
If  the  operation  is  not  done  until  after  the  age  of  two  years,  and  par- 
ticularly in  older  children  and  adults,  a  much  more  flifhcult  and  terlious 
method  will  have  to  be  employed,  and  the  patient  will  have  acquired 
improper  habits  of  speaking  which  he  never  will  be  able  completely 
to  abandon.  When  the  operation  for  cleft  palate  is  confined  to  the 
-oh  palate,  it  is  known  as  fstaphyJorrhaphy:  if  it  involves  the  hard 
palate  it  is  called  uranoplasty.  Before  operatitjn  is  undertaken  it  is 
important  that  the  patient  be  free  of  coryza,  pharyngitis,  or  other 
inflammatory  ronditions  of  the  upper  respiratory  tract. 

Early  operation. — This  consists  essentially  in  passing  sutures  of 
heavy  wire  across  the  cleft  f^above  the  horizontal  process  f)f  the  palate 

bone;  from  the  buccal  surface  of  one 
maxilla  to  that  of  the  other  (Fig.  (i88). 
These  sutures  are  then  twisted  tightly 
together  over  perforated  learl  plates;  and 
when  the  maxill*  are  thus  approximated 
the  margins  of  the  palatal  cleft  (pre- 
viously denuded)  are  sutured  together 
with  interrupted  sutures  of  silkworm  gut. 
The  wire  sutures  are  removed  after  four 
to  six  weeks*  Though  some  slight  pres- 
sure ulceration  may  occur  beneath  the 
lead  plates  no  permanent  harm  is 
done. 
Late  Operation.  —Here  the  maxilla  cannot  be  approximated,  and  it 
is  necessary  to  close  the  cleft  solely  by  means  of  the  soft  parts.    The 

'  Whitehead'.s  varnish  i.s  made  Vn-  substituting  for  the  spirit  ordinarily  u.sed  in 
the  preparation  of  "Friar's  Balsam"  (compound  tincture  of  benzoin;,  a  satu- 
rated ethereal  solution  of  iodoform,  adding  one  volume  in  t«n  of  turpentine. 


Fig.  688. — Wire  sutures  pas.sed, 
for  uranoplasty  in  infancj-. 


s(ii(;Kin'  OF  THE  Lirs  amj  i'alaik 


(•»;;<) 


marjiins  of  tlic  clct't  arc  tVeslu'iicd  first;  usually  tlicy  caiuiot  he  niacle 
to  meet  e\cii  under  j^reat  tension.  Then  an  incision  is  made  tliroufjh 
the  mucous  membrane  and  periosteum  of  the  hard  palate  close  to  the 
alxcolar  ])rocess;  this  is  not  carried  so  far  posteriorly  as  to  divide  the 
tnnik  of  the  descendinu  palatine  artery  as  it  emerges  from  the 
posterior  palatine  foramen, 
and  it  is  placed  so  close  to 
the  alveolus  as  to  lea\c 
most  of  the  branches  of 
this  artery  on  the  median 
side  of  the  incision.  Blccfl- 
ing,  which  usually  is  very 
free,  is  controlled  by  pack- 
ing the  incision  with  gauze 
which  is  allowed  to  remain, 
while  a  similar  incision  is 
made  in  the  palate  of  the 
other  side.  The  mucous 
membrane  and  periosteum 
are  now  separated  from  the 

hard  palate  by  suitable  periosteal  elevators  from  these  lateral  incisions 
to  the  median  cleft  (Fig.  ()S9).  Even  when  these  flai)s  have  been  thus 
freed,  it  may  be  impossible  to  make  the  edges  of  the  cleft  meet  in  the 
median  line  without  undue  tension.  The  higher  the  arch  of  the  palate 
the  easier  will  it  be  to  make  the  flaps  meet,  when  thus  separated 
fnmi  the  palate  above.     To  overcome  the  remaining  tension  it  may  be 


I'm.  (3.S9. — Separating  the   luufo-jjeriostoal   flap  in 
the  operation  for  cloft  palate. 


I''iG.  090. — Cnttinji  the  aponeurosis  (jf  the 
velum  at  its  insertion  in  the  hard  palate. 


Fig.  691. — Introduction  of  sutures, 
in  the  operation  for  cleft  palate. 


necessary  to  divide  the  aponeurosis  of  the  soft  palate  at  its  attachment 
to  the  hard  ])alate.  This  is  accomplishetl  by  use  of  scissors  bent  on 
the  flat  almost  to  a  right  angle;  one  blade  is  inserted  l^etween  the 
detached  mucoperiosteum  and  the  under  surface  of  the  back  of  the 
hard  palate,  and  the  other  along  the  nasal  surface  of  the  soft  palate 


640 


SURGERY  OF   THE  FACE,   MOUTH,   AND  NECK 


(Fig.  ()90).  The  freshened  edges  of  the  cleft  are  finally  united  hy  inter- 
rupted sutures  of  silkworm  gut,  passed  by  means  of  special  mounted 
needles,  as  indicated  in  P'ig.  691.  The  sutures  may  be  secured  by 
clamping  perforated  shot  over  their  ends.  The  wound  is  then 
covered  by  Whitehead's  paint. 

In  the  after-treatment  the  patient,  especially  if  an  infant,  must  be 
kept  with  the  head  low,  and  so  placed  that  vomited  matters,  mucus, 
blood,  etc.,  find  a  ready  exit.  If  no  marked  opposition  is  encountered 
it  is  well  to  spray  the  mouth  and  nasal  cavities  with  some  Aveak  anti- 
septic solution  e\ery  three  or  four  hours.  Speaking  should  not  be 
permitted  for  a  week  at  the  least.  Liquid  diet,  meat  juices,  or  broth 
being  preferable  to  milk,  should  be  employed  until  after  removal  of 
the  sutures,  when  soft  diet  may  be  allowed.  The  sutures  should  not  be 
removed  for  ten  days  unless  they  begin  to  cut  out  sooner.  If  the  opera- 
tion is  not  a  success,  from  partial  or  complete  sloughing,  another 
attempt  should  not  be  made  for  at  least  a  month,  so  as  to  allow  the 
inflammatory  swelling  to  subside. 

Acquired  Perforations  of  the  Palate,  the  result  of  syphilis,  of  trauma, 
or  of  sloughing  following  infection,  are  very  difficult  to  close  by  opera- 
tion, and  none  should  be  attempted  imtil  the  parts  are  in  healthy 
condition.  Usually  a  flap  of  mucous  membrane  must  be  inverted 
from  one  or  both  sides  of  the  perforation.  These  are  sutured  together 
and  the  denuded  area  left  to  heal  by  granulation.  In  cases  not  admit- 
ting of  operative  relief  some  form  of  obturator  should  be  worn  in  the 
form  of  a  plate  attached  to  the  teeth.  The  obturator  never  should 
be  introduced  into  the  perforation  itself,  as  this  would  surely  cause 
it  to  grow  larger  by  atrophy  from  pressure. 

Macrocheilia. — Abnormal  size  of  the  lips,  usually  the  lower,  may 
be  due  to  a  congenital  condition  of  lymphangiectasis.     This  often 

does  not  cause  marked  deformity  until 
the  age  of  puberty.  Or  the  condition 
may  be  acquired  as  the  result  of  hyper- 
trophy following  recurrent  attacks  of 
cellulitis  (Fig.  692).  It  frequently  is  ac- 
companied by  an  adenomatous  condition 
of  the  mucous  glands  of  the  lip  which 
may  be  palpable  as  shot-like  nodules 
beneath  the  mucous  membrane.  The 
treatment,  if  any  is  demanded,  consists 
in  excision  of  a  wedge-shaped  section 
all  across  the  lip,  with  suture  of  the 
mucous  to  the  cutaneous  border. 

Cysts. — Cysts  of   the  labial    mucous 

glands  form  small,  rounded,  submucous 

tumors.      They  may  follow  biting   the 

lip.     If  punctured  the  cysts  are  apt  to 

refill,  so  it  is   better  to  excise  the   anterior  wall  and  cauterize  the 

lining  membrane. 


Fig.  692. — Macrocheilia  in  a 
boy  of  seven  and  a  half  years; 
not  congenital;  followed  cellu- 
litis from  injury  at  eighteen 
months  of  age.  Orthopaedic 
Hospital. 


SURGERY  OF  THE  LIl'S  04 1 

Carbuncle.  ('ail)Uiiclc',  wIk-h  it  atlccts  tlie  upper  lij),  is  lui  unusu- 
ally serious  form  of  the  disease,  from  the  danger  of  intracranial  com- 
])lications  hy  thrombosis  and  enii)olisni  through  the  facial  and  angular 
wins.  Bullock  recently  has  collected  notes  of  27  cases,  witji  six  deatJis, 
a  mortality  of  22  per  cent.  He  advocates  and  practised  with  success 
in  one  case,  early  ligation  of  the  facial  veins  about  half  an  incli  l)elo\v 
the  inner  canthus  of  each  eye.  Early  and  free  incision  of  the  car- 
buncle is  inii)ortant,  regardless  of  aj)i)arent  deformity,  as  this  may  be 
remedied  later  by  skin-grafting  or  i)lastic  operation. 

Epithelioma. — Epithelioma  of  the  lip  is  a  frequent  condition,  and 
for  successful  treatment  rccjuires  early  recognition.  Ercfpientiy  it 
follows  clironic  local  irritation,  notably  tlie  heat  from  a  short-stemmed 
clay  pipe;  the  explanation  is  that  the  moistened  e])ithelium  sticks  to 
the  absorbent  clay  and  is  peeled  off  the  lip  as  tJie  pipe  is  removed. 
An  exfoliation  residts,  with  a  tendency  to  keratosis.  Less  than  9  per 
cent,  of  cases  of  epithelioma  of  the  lip  occur  in  women;  in  men  there 
is  only  one  case  in  the  upper  lip  to  45  in  the  lower,  while  in  women 
there  is  one  in  the  upper  to  every  7  in  the  lower  lip  (Butlin).  The 
lesion  usually  begins  to  one  side  of  the  median  line  on  the  vermilion 
border  of  the  lip  (muco-cutaneous  junction),  and  almost  without 
exception  is  of  the  more  malignant  deep-seated  type  of  epithelioma. 
An  epithelioma  begiiming  on  the  cutaneous  surface  of  the  lip  often  is 
of  the  less  malignant  superficial  type  (rodent  ulcer). 

The  deep-seated  epithelioma  growing  on  the  vermilion  border  of 
the  lip  may  arise  in  a  seborrheic  patch,  or  as  a  primary  papilloma. 
The  former  is  much  commoner.  The  lip  is  supplied  by  a  row  of  seba- 
ceous glands  which  often  are  visible  in  lips  that  appear  to  be  normal, 
"  as  a  slightly  shaded  or  as  a  glittering  band  that  stretches  like  a  bow 
across  the  front  of  the  lips  between  one  corner  of  the  mouth  and  the 
other,"  about  half  a  centimeter  above  the  cutaneous  border  (Mont- 
gomery). Somewhere  on  this  line,  crusts  tend. to  form,  and  a  typical 
seborrheic  patch  develops.  Early  invasion  of  the  regional  lymphatics 
occurs;  but  they  are  microscopically  infected  long  before  they  become 
palpable.  They  should  be  searched  for  carefully,  the  finger  of  one 
hand  being  placed  in  the  floor  of  the  mouth,  and  the  fingers  of  the 
other  hand  beneath  the  chin.  The  submental  nodes  are  those  first 
affected,  then  those  around  the  submaxillary  salivary  glands  (both 
sides),  and  finally  the  deep  cervical  lymph  nodes  along  the  great 
vessels.  The  nodes  at  first  are  indurated,  and  usually  painless;  but 
rarely  are  they  distinctly  palpable  until  the  labial  ulcer  has  existed 
for  many  months.  As  already  remarked,  long  before  they  are  palpable, 
probably  within  three  or  four  months  of  the  appearance  of  the  lip 
lesion,  microscopical  examination  of  the  submental  nodes  will  show 
the  presence  of  carcinoma  cells. 

As  time  goes  on,  the  labial  ulcer  becomes  a  foul,  fungating,  stinking 

crater;  the  cervical  lymphatics  form  conspicuous  tumors;  they  adhere 

to  the  skin  and  form  secondary  ulcers  of  the  same  foul  character  as 

in  the  lip.    The  patient  cannot  eat;  the  stench  renders  him  loathsome 

41 


042  SURGERY  OF   THE  FACE,   MOUTH,   AND  NECK 

to  himself  and  every  one  near  him;  strenfjtli  fjrachially  fails;  hemor- 
rhaj?es  from  the  growth  may  oecur;  the  trachea  or  esophagus  may  he 
compressed;  and  he  dies  a  miserable  and  painful  death,  hut  not  as 
rapidly  as  he  could  wish. 

Diagnosis. — The  diagnosis  seldom  ofi'ers  much  difficulty.  Epithe- 
lioma occurs  very  rarely  in  ])atients  under  middle  age;  it  is  predis- 
posed to  by  exposure  to  weather,  by  chrt)nic  local  irritation  of  any 
kind;  the  area  affected  is  covered  with  adherent  crusts,  which  reveal 
a  small  bleeding  ulcer  when  remo\'ed;  from  the  surface  of  the  ulcer 
it  may  be  possible  to  squeeze  out  the  epithelial  i)earls  and  columns 
of  cancer  cells  lining  the  sebaceous  ducts;  the  crusts  soon  form  again; 
and  the  regional  lymph  nodes  are  not  palpably  enlarged  until  the  lesion 
has  existed  for  a  number  of  months.  A  chancre  of  the  lip  is  of  much 
more  acute  dcAelopment;  may  cccur  at  any  age;  is  frequent  on  the 
upper  lip;  presents  parchment-like  induration;  does  not  tend  to  scab 
but  has  a  macerated  or  sloughy  surface  w^hich  is  very  little  inclined  to 
bleed;  a  history  of  contagion  usually  can  be  elicited;  lymphatic  enlarge- 
ments occurs  within  a  few  weeks,  the  nodes  being  soft  and  juicy  on 
palpation;  microscopic  examination  of  smears  from  the  lesion  usually 
will  reveal  the  presence  of  the  Treponema  pallidum;  in  due  time  skin 
lesions  make  their  appearance;  and  antisyphilitic  treatment  is  curative. 
A  (jumma  of  the  lips  is  quite  rare;  it  is  painless;  there  is  no  lymphatic 
enlargement;  the  history  or  evidence  of  other  syphilitic  lesions  usually 
can  be  obtained;  and  antisyphilitic* treatment  is  rapidly  effective. 

Prognosis. — The  expectation  of  life  in  cases  in  which  no  operation 
is  done  is  from  three  to  five  years  from  the  commencement  of  the 
disease,  and  about  eighteen  months  from  the  time  of  dift'use  lymphatic 
involvement.  If  radical  operation  is  done  before  the  lymphatics  are 
})erceptibly  enlarged,  from  50  to  60  per  cent,  of  patients  will  be  free 
from  recurrence  three  years  later;  of  those  in  whom  recurrence  takes 
place  a  small  proportion  can  be  permanently  cured  by  a  second  opera- 
tion, and  the  others  will  have  an  expectation  of  life  dating  from  the 
period  of  recurrence.  Recurrence  is  much  more  apt  to  develop  in  the 
lymphatics  than  in  the  lip;  and  a  growth  which  develops  in  the  lip  may 
not  be  a  recurrence,  strictly  speaking,  but  a  development  of  a  new 
epithelioma  from  a  seborrheic  patch  in  the  neighboring  skin  used  in 
forming  the  new  lip  at  the  first  operation. 

Treatment. — A  lesion  on  the  lower  lip  which  is  merely  suspected 
of  being  carcinomatous  should  be  excised,  with  a  margin  of  at  least 
a  quarter  of  an  inch  on  all  sides,  and  subjected  to  microscopical  exami- 
nation. If  there  is  no  evidence  of  malignancy  this  operation  may  be 
regarded  as  sufficient.  If  the  patient  refuses  to  have  the  suspected 
patch  excised,  treatment  as  for  keratosis  senilis  (page  622)  may  be 
instituted ;  but  the  surgeon  should  not  forget  that  he  is  dealing  in  the 
lower  lip  with  a  very  different  form  of  epithelioma  from  the  rodent 
ulcer  where  such  treatment  is  in  a  few  cases  successful.  There  need 
be  no  anticipation  of  success  if  the  growth  on  the  lower  lip  is  really 
an  epithelioma.    If  such  a  lesion  is  either  clinically  or  microscopically 


.si.yi'(,7t7»'r  OF  rill':  iJi'S 


M'A 


innlimKiiit,  it  is  lunrssary  to  remove  the  udjacciit  lymph  nodes  :ilso. 
'I'lie  growth  on  the  lower  lip  should  then  he  exeised  with  a  mar^nn  <)l' 
at  least  a  half  inch  on  each  sid'',  hy  incisions  at  ri,u;ht  angles  to  the  line 
of  the  lip,  not  hy  a  \-shaped  incision. 

The  ()peniti(.n  introduced  by  (Jrant,  of  1  )<'nver  (1899),  usually  is 
cnii)loyed  now  (Fi^^.  ()9;>  and  (■)94).  After  excision  of  the  lesion,  usu- 
all\  including-  most  of  the  lower  lip,  in  form  of  a  rectan^de,  incisions  are 
carried  downward  and  outward  from  the  lower  angles  of  this  rectangle, 
so  as  to  expose  the  suhiuaxillary  region  on  each  side.  These  regions 
are  then  cleared  of  lymi)h  nodes,  ligating  the  facial  vessels  if  necessary. 
Finally  the  submental  l.\  ni])h  nodes  are  removed  through  a  separate 
median  incision.  By  drawing  together  in  the  median  line  the  fiaps 
outlined  hy  the  two  lateral  incisions,  the  lower  lip  is  well  restored 
without    further  i)lastic  ])rocedure.     The  other  chief  merit  claimed 


Fig.  693. — Grant's  operation  for  epithe- 
lioma of  the  lower  lip. 


Fig.  694. — Grant's  operation 
completed. 


for  this  operation  is  that  it  leaves  the  point  of  the  chin  untouched, 
and  that  this  serves  as  a  firm  basis  of  support  for  the  new  lower  lip. 
But  it  will  be  noted  that  this  method  of  operation  does  not  remove 
the  labial  growth  in  one  mass  with  its  related  lymphatics,  but  extir- 
pates the  diseased  tissue  in  three  or  four  separate  sections.  ^Moreover, 
the  cavity  of  the  mouth  is  opened  as  the  first  step  in  the  operation, 
exposing  the  entire  wound  to  contamination  during  the  tedious  dis- 
section of  the  submaxillary  and  submental  regions. 

For  these  reasons  I  think  it  is  l)etter  to  commence  the  operation 
by  the  removal  of  the  submental  and  su})maxillary  lymphatics.  These 
regions  are  well  exposed  b\-  making  a  long  cur\'ed  incision  which  cor- 
responds to  those  incisions  of  Grant's  operation  which  are  represented 
hv  solid  lines  in  Fig.  693.  The  skin  over  the  point  of  the  chin  may  be 
left  attached  by  carrying  this  first  incision  a  little  lower  than  indicated. 
The  flap  thus  outlined  is  (tissected  dowaiward,  including  with  the  skin 


(544  SURGERY  OF   THE  FACE,   MOUTH,   AND  NECK 

only  the  platysma,  and  leavinj^  the  fatty  and  lymphatic  tissues  m  situ. 
When  the  submental  and  both  submaxillary  regions  have  been  exposed 
in  this  way  they  are  cleared  of  lymphatics  and  fat  by  dissection  from 
below  upward;  and  the  diseased  structures  are  removed.  Incisions 
are  then  made  upward  into  the  mouth  on  each  side  of  the  labial 
growth,  and  the  lower  lip  is  excised.  The  submental  flap  is  then 
sutured  to  the  point  of  the  chin,  and  the  lateral  flaps  are  united  in  the 
median  line  as  in  Grant's  operation.  It  is  well  to  drain  both  sub- 
maxillary regions  from  the  outer  angles  of  the  lateral  incisions  for 
several  days.  Where  the  dissection  has  been  very  extensive  it  is 
better  to  carry  a  tube  from  the  submental  region  in  the  median  line 
through  the  floor  of  the  mouth,  draining  the  buccal  secretions  directly 
into  the  dressings,  and  thus  lessening  the  chance  of  infecting  the 
suture  lines.  The  portions  of  the  skin  incisions  not  drained  should 
be  painted  with  Wliitehead's  varnish  (p.  638). 

SURGERY  OF  THE  TONGUE. 

Tongue-tie.  —  It  happens  occasionally,  though  not  so  often  as 
mothers  believe,  that  an  infant  is  born  with  congenital  shortness  of 
the  frcBmim  lingncB.  The  tongue  then  is  held  against  the  floor  of  the 
mouth,  cannot  be  protruded  beyond  the  alveolar  margin,  and  may 
occasion  slight  difficulty  in  suckhng.  The  condition  is  easily  remedied 
by  snipping  with  scissors  the  tense  band  close  to  the  floor  of  the 
mouth  (to  avoid  the  ranine  vessels  which  run  beneath  the  tongue), 
and  then  stripping  the  tongue  upward  by  the  fingers  as  far  as  needed. 
The  bifid  blade  at  one  extremity  of  the  grooved  director  (Fig.  700)  is 
a  convenient  retractor  to  hold  the  tongue  away  from  the  floor  of  the 
mouth,  while  the  frenum  is  being  divided.  If  the  separation  of  the 
tongue  from  the  floor  of  the  mouth  is  carried  too  far,  there  is  danger 
of  the  baby  being  suft'ocated  by  "swallowing"  the  tongue. 

Macroglossia. — Abnormal  enlargement  of  the  tongue,  when  not 
dependent  upon  constitutional  causes,  such  as  cretinism,  may  be 
congenital  or  acquired,  as  in  the  pathologically  analogous  condition 
of  macrocheilia  (p.  640),  and  from  similar  causes.  In  congenital 
cases  the  patients  usually  are  mentally  deficient.  The  protruding 
tongue  becomes  inflamed  and  dry  from  exposure  to  the  air,  resulting 
in  stomatitis,  with  collection  of  sordes,  fetor  of  the  breath,  etc.  In 
time  the  incisor  teeth  of  both  jaws  are  pressed  forward  and  the  alveolar 
processes  are  distorted ;  but  this  deformity  rarely  becomes  permanent 
before  the  tenth  year. 

Treatment. — Treatment  consists  in  partial  excision,  usually  of  a 
wedged-shaped  portion  of  the  tip  of  the  tongue,  with  suture  of  the 
remaining  lateral  flaps  in  the  mid-line.  Or,  as  the  thickness  of  the 
tongue  usually  is  more  obnoxious  than  its  breadth,  a  transverse  resec- 
tion may  be  done,  making  superior  and  inferior  flaps.  Preliminary 
ligation  of  the  lingual  arteries  may  be  advisable  if  the  tongue  is  very 
large,  and  Armstrong  recommends  the  use  of  silver  wire  instead  of 


HVIiCEUY  OF  THE  TONGUE 


045 


silkworm  mit  for  suturing  the  tonjiuo.     The  best  time  for  operation 
is  from  the  third  to  the  sixtii  year. 

Ranula.  UaiuiUi  is  a  eystie  tumor  between  the  tonj^ue  and  the  floor 
of  the  moutii.  It  is  a  ehnieal  term,  possibly  deseriptive  of  the  frog- 
like appearance  of  patients  when  the  growth  is  very  large.  Though 
occasionally  congenital,  in  the  vast  majority  of  cases  it  is  acquired; 
usually  it  is  considered  a  retention  cyst  of  one  of  the  sublingual  glands 
or  its  duct.  It  is  not  improbable  that  its  pathogenesis  is  similar  to 
that  of  galaetocele  (p.  703).  Occasionally  a  salivary  calculus  may 
be  the  cause  of  obstruction  of  the  duct,  but  as  a  rule  no  cause  can  be 
found.  The  cyst  in  most  cases  is  of  slow  development  and  chronic  in 
(hiration.  It  is  unilocular.  Conditions  described  as  acute,  and  as  inter- 
mittent  ranula  are  also  recognized,  though  very  rare.  In  the  acute 
cases  a  swelling  suddenly  a])pears  beneath  the  tongue,  the  mucous 
membrane  lining  the  floor  of  the  mouth  is  raised  above  the  dental 
border,  salivation  is  profuse, 
speech,  deglutition,  and  even 
respiration  are  interfered  with, 
and  suffocation  may  threaten. 
Astringent  washes  usually  are 
sujQficient  to  relieve  the  symp- 
toms, and  the  cystic  swelling 
may  disappear  as  rapidly  as  it 
came,  as  w^as  the  case  in  the 
only  patient  with  this  rare  af- 
fection I  have  seen;  but  some- 
times incision  is  required.  In 
the  chronic  cases  the  cyst, 
though  unilateral  at  first,  may 
spread  so  as  to  involve  the 
entire  sublingual  region;  very 
seldom  at  the  present  day  is 
it  allowed  to  grow  so  large  as  to  project  in  the  submental  region. 
The  mucous  membrane  slides  freely  over  it,  and  its  surface  often  is 
covered  with  dilated  and  tortuous  veins  (Fig.  695) ;  it  is  semi-trans- 
lucent, and  the  contents  are  a  viscid,  ropy,  mucus.  Ranula  is  most 
likely  to  be  confounded  with  dermoid  cysts,  which,  however,  are  rare; 
a  dermoid  cyst  has  thicker  walls,  pits  on  pressure,  and  is  not  trans- 
lucent. 

Treatment. — Excision  of  the  anterior  wall  of  the  cyst,  and  scraping 
or  cauterizing  the  remaining  portion  of  the  lining  membrane,  and 
packing  the  cavity  with  gauze  until  healing  by  granulation  takes 
place,  usually  effect  a  cure.  But  unless  a  thorough  operation  is  done 
and  the  after-treatment  efficiently  conducted,  recurrence  will  take 
place.  The  operation  can  be  done  under  cocain  anesthesia,  through 
the  mouth. 

Ludwig's  Angina,  or  Angina  Ludovici,  is  a  condition  first  accurately 
described  by  Ludwig  in  1834.     It  is  an  acute  septic  inflammatory 


Fig.  695. — Ranula.  Age  eleven  years; 
duration  over  one  year.  Projecting  cyst  is 
dark  blue  from  overlj-ing  vein.  Episcopal 
Hospital. 


()4()  SURGERY  OF   THE  FACE,   MOUTH,   AND  NECK 

process  involving  the  cellular  tissues  of  the  floor  of  the  mouth  and  the 
submaxillar!/  region  of  one  or  both  sides  of  the  neck.  It  is  imjjortant  to 
note  that  in  this  definition  the  main  chnical  features  of  the  disease  are 
indicated.  It  affects  the  coiniective  tissue  spaces,  being  a  ceUuhtis, 
as  asserted  by  G.  G.  Davis  (190G),  not  a  lymphangitis;  the  lymph 
nodes  and  the  submaxillary  and  sublingual  salivary  glands  are  not 
primarily  diseased,  but  may  be  invaded  secondarily.  It  involves  both 
the  floor  of  the  mouth  and  the  cervical  tissues.  It  is  not  confined  to 
either.  Usually  it  owes  its  origin  to  infection  from  dental  lesions, 
and  often  commences  after  the  extraction  of  teeth;  but  it  may  begin 
in  the  tonsil  or  other  intrabuccal  structure.  The  cellulitis  spreads 
with  great  rapidity  from  the  floor  of  the  mouth  around  the  posterior 
border  of  the  mylo-hyoifl  muscle,  a  route  to  which  attention  was 
called  by  T.  T.  Thomas  in  1907.  Both  sides  of  the  neck  are  affected. 
The  submaxillary  gland  and  lymph  nodes  usually  are  found  more  or 
less  intact  in  the  centre  of  a  necrotic  area  of  cellular  tissue. 

It  is  not  unusual  for  groups  of  patients  to  be  affected  nearly  simul- 
taneously, but  the  disease  does  not  seem  to  be  contagious. 

Symptoms. — The  onset  of  the  disease  is  marked  usually  by  difficulty 
in  talking  and  swallowing,  pain  in  the  floor  of  the  mouth,  salivation, 
and  finally  dyspnea.  The  patient  becomes  profoundly  septic,  but 
gives  evidences  of  little  or  no  constitutional  reaction.  The  temjiera- 
ture  often  is  not  very  high,  nor  is  there  marked  leukocytosis.  Edema 
of  the  glottis  may  occur  at  any  time,  and  T.  T.  Thomas  believes  this 
is  the  usual  cause  of  death;  but  in  many  cases  death  seems  to  be  due 
to  toxemia,  and  suft'ocati^'e  symptoms  are  entirely  absent. 

Diagnosis. — The  diagnosis  depends  on  recognizing  a  possible  cause; 
on  demonstrating  a  cellulitis  both  in  the  floor  of  the  mouth  and  in  the 
upper  cervical  regions,  perhaps  extending  to  the  clavicle,  and  often 
more  marked  on  one  side;  and  on  the  rapid  progress  of  the  disease 
to  a  fatal  termination  unless  relieved  by  efficient  treatment. 

Treatment. — As  soon  as  the  diagnosis  is  made,  and  without  waiting 
for  the  development  of  more  serious  symptoms,  the  parts  should  be 
incised.  This  may  be  done  under  local  anesthesia;  general  anesthesia 
may  be  out  of  the  question,  owing  to  the  sufl'ocative  symjitoms.  An 
incision  is  made  directly  in  the  median  line  in  the  submental  region, 
between  the  genio-hyoid  muscles;  the  knife  is  pushed  up  into  the  floor 
of  the  mouth,  emerging  just  behind  the  symphysis  menti.  There  are 
no  structures  of  importance  in  the  median  line.  A  drainage  tube  is 
then  drawn  through  from  the  submental  region  to  the  floor  of  the  mouth. 
An  incision  is  then  made  in  one  or  both  submaxillary  regions,  and  a 
tract  is  made  by  thrusting  a  hemostat  into  the  mouth  through  the 
mylohyoid  muscle.  Tubes  are  then  inserted  in  these  additional  tracts; 
or  one  long  tube  may  be  made  to  pass  from  one  submaxillary  region 
to  the  other  across  the  floor  of  the  mouth  a})ove  the  mylohyoid  muscle 
(Fig.  696).  In  addition,  if  the  sublingual  tissue  is  markedly  edematous, 
it  is  well  to  incise  the  mucous  membrane  of  the  floor  of  the  mouth 
from  the  mid-line  to  the  second  molar  tooth,  as  advised  bv  J.  W. 


Sl'h'dl'Hn'  OF   THE   TOXdl'K 


(;i7 


Fig.  696. — Ludwig's  angina,  in  a 
patient  of  twenty-two  years.  After 
operation.  (Dr.  J.  W.  Price,  Jr.'s 
ca.se.)      Episcopal  Hospital. 


Price  (190S),  and  <i;('iitly  to  curette  wluTcNcr  a  soft  spot  is  t'ouiid. 

I'sually  little  or  no  pus  is  found,  the  infection  heinj:;  so  severe  that  the 

tissues  are  unahle  to  react.     The  i)arts  are  dressed  with  hot,  moist 

antiseptic  i;au/e,  to  form  a  j)oultice. 

Concentrated   mitriment  and  stinni- 

hmts  should  l)e  jii\-en.    Traclieotomy 

is  recpiircd  when  edema  of  the  <;Iottis 

occurs.   The  mortahty  of  theafi'ection 

has  varied  from  20  to  40  ])er  cent., 

in  different  series  of  ea.ses. 

Glossitis.  Acute  Superficial  Glossi- 
tis may  foUow  hums,  scahls,  or  other 
injuries,  and  the  lesion  may  be 
catarrhal  in  character,  or  associated 
with  destruction  of  the  mucous  mem- 
brane and  the  formation  of  one  or 
more  ulcers.  Stomatitis  of  similar 
form  may  coexist.  Healing  readily 
occurs,  as  a  rule,  under  the  influence 
of  alkaline  mouth  washes.  An  indo- 
lent ulcer  may  be  touched  with  a 
drop  of  pure  carbolic  acid. 

Acute  Parenchymatous  Glossitis,  in 
which  the  tongue  suddenly  becomes 
immensely  swollen,  threatening  suft'ocation,  is  described  by  system- 
atic writers.  It  is  an  infectious  process,  analogous  to  but  rarer  than 
Lud wig's  angina,  and  not  aft'ecting  the  sublingual  nor  the  cervical 
tissues.  Treatment  consists  in  incising  the  dorsum  of  the  tongue 
to  the  depth  of  5  to  10  mm.,  each  side  of  the  median  raphe,  for  a  dis- 
tance of  about  two  inches.    This  rapidly  relieves  the  .swelling. 

Abscess  of  the  Tongue  may  be  acute  or  chronic.  P'ither  form  is  rare, 
and  the  chronic  form  may  be  indistinguishable  from  a  dee])  gumma 
of  the  tongue.  If  fair  trial  of  antisyphilitic  treatment  causes  no 
improvement,  an  exploratory  incision  should  be  made.  Incision  is 
the  proper  treatment  also  for  acute  abscess. 

Chronic  Superficial  Glossitis  is  known  by  various  other  names,  more 
or  less  descriptive  of  different  stages  of  the  disease.  The  best  known 
and  most  used  is  Leukoplakia.  Other  names  are  Leukoma,  Leuko- 
keratosis,  Smokers'  Patches,  Psoriasis,  and  Ichthyosis  of  the  Tongue. 
These  conditions  derive  their  surgical  importance  from  the  fact  that 
they  are  recognized  as  precancerous  diseases,  analogous  to  the  senile 
keratosis  of  the  skin  discussed  at  page  ()22.  The  pathological  change 
in  the  tongue  consists  in  a  proliferation  of  the  epithelial  cells,  col- 
lection of  leukocytes,  and  scar  formation  immediately  beneath  the 
epithelial  layer.  The  patches  may  occur  on  the  tongue  alone,  on  the 
cheeks  and  lips  alone,  or  on  both  tongue  and  other  buccal  surfaces. 
They  are  seen  oftenest  on  the  dorsum  of  the  tongue  near  its  tip,  but 
not  in  the  median  line.     Thev  never  occur  behind  the  circumvallate 


CAS  SURGERY  OF  THE  FACE,   }fOUTH,   AND  NECK 

papillse.  They  may  be  small  or  large,  irregular,  circular,  circinate,  or 
"geographical"  in  outline;  they  always  spread,  and  different  patches 
frequently  coalesce.  Early  in  the  disease  the  patches  appear  as  red, 
shiny,  smooth  areas  on  the  tongue,  surrounded  by  a  distinctly  furred 
area  of  mucous  membrane  (Smokers'  Patches).  Later  these  patches 
become  bluish  white,  but  retain  their  characteristic  smoothness 
(Leukoplakia).  Still  later  some  evidences  of  thickening  and  indura- 
tion are  present,  the  patches  are  furrowed,  and  the  fissures  may  be 
ulcerated  (Leukokeratosis).  This  stage  borders  on  the  development 
of  carcinomatous  changes. 

Cause. — The  cause  of  this  affection  is  not  known,  but  is  definitely 
related  to  several  forms  of  chronic  irritation.  Of  these  the  most  impor- 
tant is  smoking  or  the  use  of  tobacco  in  any  form;  probably  it  is  the 
chemicals  in  the  tobacco,  combined  with  the  mechanical  irritation, 
and,  in  the  case  of  smoke,  the  heat,  that  renders  its  use  so  harmful. 
But  many  cases  occur  in  those  who  have  never  used  tobacco.  Other 
predisposing  causes  are  syphilis,  when  its  tertiary  stage  is  reached; 
psoriasis,  or  ichthyosis,  elsewhere  in  the  body;  the  presence  of 
broken,  or  decayed  teeth;  irritation  from  badly  fitting  vulcanite 
dental  plates,  etc. 

Symptoms. — The  earliest  symptom,  which  may  be  overlooked  for 
many  months,  is  smarting  in  the  tongue  after  excessive  smoking  or 
drinking;  later,  pain  is  felt  whenever  highly  seasoned  or  hot  food  is 
taken.  But  the  patient  may  discover  the  patches  accidentally,  on 
looking  in  the  mirror;  or  they  may  be  called  to  his  attention  by  his 
dentist  or  physician  before  any  definite  symptoms  have  arisen. 

Treatment. — The  use  of  tobacco  in  any  form  should  be  absolutely 
prohibited  until  entire  disappearance  of  the  lesions.  Any  other  form 
of  irritation,  whether  due  to  dental  conditions  or  dietary  indiscretions, 
should  be  remedied,  and  unirritating,  preferably  alkaline,  mouth 
washes  should  be  ordered.  Cauterization  of  the  lesions  usually  makes 
them  worse.  If  there  is  a  single,  small,  localized  lesion,  it  may  be 
excised.  If  epithelioma  is  suspected,  a  portion  of  the  patch  should 
be  excised  for  microscopical  examination. 

Tuberculosis. — Tuberculosis  of  the  tongue  is  rare.  The  lesion 
commences  as  a  tuberculoma,  but  very  seldom  is  it  seen  until  this  has 
broken  down,  leaving  an  ulcer.  Usually  the  lesion  is  secondary  to 
tuberculous  disease  elsewhere  (lungs  or  larynx),  and  this  gives  the 
clue  to  the  diagnosis.  The  tuberculous  ulcer  appears  at  the  tip  or 
edges  of  the  tongue,  rarely  on  the  dorsum;  it  is  superficial  and  lies  in 
the  long  axis  of  the  tongue;  it  is  not  indurated;  has  not  raised  or 
thickened  borders;  secretes  thick  and  yellowish  pus;  and  may  be 
surrounded  by  caseous  foci.  It  is  commonest  in  men  and  in  adults 
(Plate  IV,  Fig.  1).  The  ulcer  is  very  painful.  Early  invasion  of  the 
cervical  lymph  nodes  is  usual. 

Treatment. — In  the  very  rare  cases  where  tuberculosis  is  primary 
in  the  tongue  it  is  proper  to  excise  the  lesion  together  with  the  enlarged 
lymph  nodes.    In  most  cases,  however,  nothing  can  be  done  save  to 


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SURGERY  OF  THE  TONGUE  G40 

relieve  the  pain  l)y  loeal  use  of  cocain  or  other  anesthetic.  Armstrong 
says  si)rayin^-  the  all'ected  area  with  ;i  1  per  cent,  solution  of  carh(jlic 
acid,  to  which  a  Httle  sodium  hi(  arhonate  has  heen  added,  sometimes 
is  soothing. 

Syphilis.- -Syphilis  of  the  tongue  is  of  most  surgical  interest  in  the 
gununatous  stage.  Chaiicrr  and  )iincou6-  paiclici  of  the  tongue  and 
mouth  present  the  same  characteristics  as  these  lesions  elsewhere, 
and  their  diagnosis  seldom  is  difficult.  Gumma  of  the  tongue  may  be 
single  or  multiple,  superficial  or  deep.  The  lesions  occur  chiefly  on 
the  dorsum  of  the  organ;  they  soon  break  down,  and  are  a])t  to  coalesce, 
forming  large  irregular,  nearly  painless  ulcers  with  overhanging  edges 
and  covered  with  an  adherent  slough.  The  ulcers  do  not  tend  to 
bleed  when  the  slough  is  pulled  away;  they  are  not  indurated;  they  are 
not  accompanied  or  followed  by  enlargement  of  the  cervical  lymph 
nodes;  a  history  of  i)revious  syphilitic  lesions  usually  can  be  obtained; 
and  they  rapidly  improve  under  the  administration  of  the  iodides. 
These  features  serve  to  distinguish  them  from  carcinomatous  ulcers 
(p.  650).  Diffuse  gummatous  glossitis  as  it  heals  leaves  a  charac- 
teristically fissured  and  furrowed  tongue  (Plate  IV,  Fig.  2). 

Sarcoma.— Sarcoma  of  the  tongue  is  very  rare.  Serafini,  in  1910, 
reported  what  he  believed  w^as  only  the  thirty-second  case  on  record. 

Carcinoma. — In  the  tongue  this  occurs  almost  invariably  in  the 
form  of  ei)itlielioma,  though  a  few  cylindrical-celled  carcinomas  have 
been  recorded.  It  is  much  more  common  in  men  than  in  women 
(about  15  to  1),  and  quite  unusual  before  middle  life.  Frequently  it 
seems  to  be  brought  on  by  chronic  irritation,  such  as  that  from  a 
broken  tooth,  from  tobacco  smoke,  or  the  stem  of  a  pipe  (Plate  IV, 
Fig.  3).  The  pre-cancerous  lesions  of  the  tongue  already  have  been 
discussed  (p.  647),  and  Butlin  demonstrated  not  long  ago  that  many 
lesions,  previously  considered  by  him  and  others  as  pre-cancerous, 
prove  on  microscopical  examination  to  be  actually  malignant. 

Usually  the  epithelioma  begins  in  a  fissure,  an  ulcer,  or  a  patch  of 
leukoplakia.  Sometimes,  but  rarel}',  it  appears  first  as  a  wart  or 
papilloma;  and  any  such  growth  on  the  tongue  which  does  not  disap- 
pear very  promptly  after  removal  of  a  recognized  source  of  irritation 
should  be  considered  malignant.  The  epithelioma  commonly  appears 
on  the  lateral  margin  of  the  tongue,  very  rarely  at  the  tip,  and  almost 
never  on  the  dorsum.  It  begins  occasionally  as  a  submucous  growth, 
but  even  in  such  cases  it  is  very  seldom  seen  until  an  ulcer  has  formed ; 
and  in  the  vast  majority  of  instances  it  develops  in  a  preexisting 
erosion  or  ulcer.  It  may  begin  in  the  floor  of  the  mouth,  but  it  is 
more  usual  for  this  to  be  invaded  secondarily.  A  cancer  in  the  ante- 
rior third  of  the  tongue  tends  to  spread  to  the  floor  of  the  mouth  and 
mucous  membrane  covering  the  alveolus;  it  early  invades  the  sub- 
mental and  submaxillary  lymph  nodes,  first  those  on  the  same  side  as 
the  grow^th,  but  later  the  involvement  is  bilateral.  Next  the  deep 
cervical  chain  is  invaded.  The  submaxillary  and  sublingual  salivary 
glands  usually  are  not  invaded.    A  cancer  in  the  yosterior  two-thirds 


650 


SURGERY  OF   THE  FACE,   MOI'TH,   AXD  NECK 


of  the  tongue  tends  to  spread  to  the  soft  palate  and  pharynx;  it  invades 
the  lymphatics  of  both  sides  very  early;  first  the  submaxillary,  then 
the  deep  cervical.  When  the  latter  have  been  invaderl  by  cancer 
arising  in  any  part  of  the  tongue,  the  growth  spreads  up  their  chain 
to  the  base  of  the  skull  and  downward  to  the  clavicle.  Distant 
metastases  occur  very  late  and  are  quite  unusual.  In  the  vast 
majority  of  cases  the  disease  is  distinctly  limited  to  the  face  and  neck. 
When  once  the  cervical  lymph  nodes  are  invaded,  the  tumor  may 
grow  in  them  with  alarming  rapidity,  and  these  secondary  growths 
may  quite  over-shadow  the  original  trouble.  The  same  progressively 
fatal  course,  but  even  more  rapidly,  is  observed  here  as  in  the  cervical 
growtlis  following  carcinoma  of  the  lip  (p.  641). 

Symptoms. — Pain  and  smarting  in  the  diseased  area,  especially 
on  smoking,  drinking  alcoholic  beverages,  or  eating  hot  or  highly 

seasoned  food,  usually  are  the 
first  things  to  attract  the  patient's 
attention.  The  tongue,  or  the 
whole  mouth,  may  feel  sore. 
There  is  difhculty  and  pain  in 
swallowing,  and  the  patient 
refrains  from  eating.  Later 
even  liquids  can  scarcely  be 
taken.  The  tongue  feels  thick 
and  clumsy.  Speech  becomes  in- 
distinct. Salivation  is  increased. 
Pain  may  be  referred  to  the  ear 
if  the  growth  is  far  back  in  the 
tongue.  Very  rarely  is  pain  al- 
together absent ;  but  occasionally 
the  patient  is  unaware  of  his 
condition  until  the  tumor  is . 
inoperable.  From  inability  to 
eat,  sleepless  nights,  and  constant  pain,  the  patient  rapidly  becomes 
emaciated.  If  secondary  infection  occurs,  there  will  be  added  fever- 
ishness,  chilliness,  and  increased  secretion  from  the  tumor,  with  hor- 
rible fetor  of  the  breath.  Hemorrhages  may  occur  from  the  mouth 
or  from  secondary  ulcers  in  the  neck.  Death  may  occur  from  such  a 
complication  or  from  septic  inhalation  pneumonia,  but  more  often 
follows  a  short  period  of  delirium  due  to  toxic  absorption. 

Diagnosis. — Carcinoma  of  the  tongue  must  be  distinguished  chiefly 
from  tuberculous  and  syphilitic  ulcerations.  The  characteristics  of 
these  have  been  considered  already  (p.  648);  but  it  should  not  be 
forgotten  that  carcinoma  frequently  develops  in  a  syphilitic  lesion. 
In  carcinoma  the  main  diagnostic  points  are  the  hardness  of  the 
ulcer's  base;  the  thickness  f)f  its  margins,  the  bleeding  when  the  adher- 
ent slough  is  removed,  exposing  an  uneven  floor;  the  patient's  age; 
and  the  existence  of  some  chronic  form  of  local  irritation.  Any  ulcer 
even  suspected  of  being  carcinomatous  should  l)e  subjected  to  micro- 


FiG.  697. — Recurrent  carcinoma  of  floor 
of  mouth.  Excision  of  tongue  by  intra- 
buccal  method  in  September,  1909,  three 
months  after  appearance  of  growth.  Re- 
currence in  Xoveml)er.  1909.  Photograph 
February  14,  1910.  ^E>r.  H.  C.  Deaver's 
case.)      Episcopal   Hospital. 


s[R(;KRy  or  the  roxacE  i\n\ 

scopical  study.  A  portion  ol'  tlu'  ulcer  may  ])v  rcniowd  easily  hy 
pullin<i  tlie  touffue  far  out  of  the  nioutli  and  injeetinj;  a  few  euhic  centi- 
meters of  eucain  solution  ((>  j)er  cent.)  beneath  the  ulcer;  a  portion 
of  the  indurated  margin  of  the  nicer  is  then  pinched  up  in  forceps  and 
cut  oH'  with  scissors.  I^nlarj^enient  of  tlie  lympli  nodes  never  should 
be  depended  u|)on  for  a  clinical  diagnosis.  Lonjj  before  they  are  palpa- 
ble they  arc  nncrosc()])icall\'  diseased,  ^'et  the  presence  of  enlarj,a'd 
lymph  nodes  points  to  carcinoma  rather  than  to  <i  tertiary  syphilitic 
lesion. 

Prognosis.  In  cases  entirely  untreated,  the  expectation  of  life  is 
not  more  than  eijjhteen  months  from  the  time  the  growth  is  recog- 
nized. In  many  cases  death  occurs  in  less  than  nine  months.  By 
radical  surgical  treatment  the  expectation  of  life  is  almost  doubled, 
and  a  certain  luimber  of  patients  (25  per  cent,  in  Butlin's  statistics), 
in  whom  early  oj)eration  is  tlone,  remain  free  of  recurrence  for  many 
years  or  until  death  from  some  other  malady.  Even  in  cases  where 
recurrence  takes  place,  this  is  almost  always  in  the  neck,  and  the 
patient  is  still  able  to  take  nourishment  and  does  not  suffer  nearly  so 
much  ])ain  as  if  the  tumor  was  still  growing  in  the  mouth.  The  imme- 
diate mortality  after  radical  operation  is  in  general  from  15  to  20  per 
cent.  It  is  lower  in  uncomplicated  eases,  and  much  higher  when  part 
of  the  mandible  or  pharynx  has  to  be  removed. 

Treatment.- — Owen  well  says  that  most  of  these  patients  come  to  the 
surgeon  when  the  tumor  is  so  far  advanced,  that  if  he  considered  only 
his  own  peace  of  mind  he  would  decline  to  undertake  any  operation. 
But  whenever  it  is  not  inoperable,  radical  removal  of  the  growth  and 
the  ralated  lymph  nodes  is  the  only  rational  treatment.  In  deciding 
for  or  against  operability,  the  surgeon  should  examine  especially  the 
local  extent  of  the  disease,  and  the  range  of  lymphatic  involvement. 
A  caiK^er  of  the  tongue  cannot  be  considered  inoperable  merely  because 
it  has  invaded  the  floor  of  the  mouth  or  has  eaten  into  the  mandible. 
But  if  the  entire  floor  of  the  mouth,  on  both  sides,  is  densely  infiltrated, 
and  especially  if  the  growth  has  extended  along  the  anterior  pillar 
of  the  fauces  to  the  soft  palate  or  pharynx,  it  generally  will  be  impos- 
sible to  cut  wide  enough  of  the  growth  to  ensure  freedom  from  local 
recurrence.  In  regard  to  lymphatic  involvement,  the  surgeon  should 
examine  carefully  and  repeatedly  the  deep  cervical  lymphatics  extend- 
ing u])  to  the  l)ase  of  the  skull.  If  these  are  manifestly  involved,  and 
certainly  if  they  are  immovably  adherent  to  the  spinal  muscles  or  the 
skull  itself,  he  should  decline  to  interfere  with  them.  Involvement 
of  the  lymphatics  downward  is  not  so  serious  a  matter,  since  it  is 
very  seldom  that  the  disease  process  passes  beyond  the  subclavian 
triangle;  and  the  contents  of  this  triangle  and  those  above  it  can  be 
removed  with  comparative  facility  by  modern  methods. 

]\Iost  surgeons  prefer  to  do  in  two  stages  whatever  form  of  operation 
is  undertaken.  Armstrong,  however,  removes  both  the  lymph  nodes 
and  the  tongue  at  the  same  sitting.  Usually  the  lingual  growth  is 
removed  first;  and  after  a  week  or  ten  days  the  cervical  lymphatics 


052  SFRGERY  OF   THE  FACE,   MOJ'TH,   AXfJ  XECK 

are  dissected  out.  In  early  cases  (3  to  o  months'  duration)  it  may  be 
sufficient  to  remove  the  lymphatics  only  from  the  bifurcation  of  the 
carotid  up  to  the  tongue  and  base  of  the  skull;  in  more  advanced 
cases  the  dissection  must  commence  as  low  as  the  clavicle.  If  only 
the  anterior  third  of  the  tongue  is  involved,  most  surgeons  consider 
it  sufficient  to  remove  the  submental  nodes  and  the  cervical  nodes  of 
the  same  side  as  the  lingual  lesion;  but  Da  Costa  urges  that  even  in 
such  cases  the  cervical  lymphatics  also  on  the  other  side  should  be 
excised,  as  he  has  found  them  involved  at  a  very  early  stage.  Nearly 
all  authorities  are  agreed  that,  when  the  tumor  involves  the  posterior 
part  of  the  tongue,  the  lymphatics  from  both  sides  of  the  neck  ought 
to  be  removed.  This  may  require  the  division  of  the  operation  into 
three  stages.  Owen  recommends,  if  the  lymph  nodes  are  increasing 
very  rapidly  in  size,  that  the  first  operation  should  consist  in  extirpat- 
ing them,  since  if  the  tongue  is  removed  first,  and  the  operation  on 
the  Ijinph  nodes  postponed  for  a  couple  of  weeks,  they  may  have 
become  inoperable  by  that  time. 

The  questions  of  the  preparation  of  the  patient  and  of  the  anesthetic 
are  of  importance.  For  several  days  previously  special  attention 
should  be  given  to  cleansing  the  patient's  mouth,'  and  improving  so 
far  as  possible,  his  general  health.  Xo  operation  should  be  done  while 
there  is  an  acute  bronchial  or  pulmonary  lesion.  The  anesthetic, 
preferably  ether,  should  be  given  by  a  skilled  anesthetist;  wherever 
possible  (and  this  should  be  the  case  in  every  well  appointed  hospital) 
the  method  of  intratracheal  insufflation  (p.  154j  should  be  employed. 
This  minimizes  or  altogether  prevents  the  chance  of  pulmonary  com- 
plications, and  permits  the  operation  to  be  done  in  the  head-high 
position,  which  markedly  decreases  the  quantity  of  blood  lost.  If 
this  method  cannot  be  used,  one  of  the  other  methods  recommended 
at  p.  153  for  operations  on  the  head  and  neck  should  be  employed. 
A  h\"podermic  of  morphin  and  atropin  should  be  given  shortly  before 
beginning  the  operation. 

The  cervical  lymphatics  are  well  exposed  by  the  incisions  recom- 
mended by  Butlin  (Fig.  698).  The  two  triangles  outlined  are  dissected 
free,  the  flaps  being  composed  of  skin  alone,  especially  in  the  submental 
and  submaxillary  regions.  If  necessary  another  incision  may  be  carried 
out^^'ard  along  the  clavicle.  All  the  fat  and  lymphatic  tissues  are  then 
cleared  out  in  one  mass,  beginning  at  the  cla^'icle  and  working  upward 
along  the  great  vessels  and  forv^-ard  to  the  region  of  the  jaw.  The 
common  carotid  artery  may  be  temporarily  clamped,  close  to  the 
subclavian.  The  sternomastoid  muscle  may  be  divided  or  excised 
with  the  deeper  structures  to  facilitate  the  dissection.     The  internal 

II  have  used  Talbot's  iodo-glycerole  mouth  wash  with  good  efifect  before  and 
after  operation: 

^ — Zinci  iodidi  Cpur.),         3  parts 
Water,  2     " 

lodin  cr\'stal.«,  5     " 

Gljcerin,  10     " 


SURGERY  OF   TllK  TONdUE 


()5:i 


juuiilar  vein  may  be  excised  if  the  ^aowth  is  densely  udiiereiit;  and  the 
va^us  nerve,  and  even  the  eoniinon  earotid  artery  may  be  extirpated 
if  neeessarv.'  lUit  in  tiiose  i)ast  fifty  years  of  aj^e  removal  of  the  (-arotid 
is  inadvisable  on  aeeount  of  the  danger  of  softening  of  the  bram  and 
paralysis  (Crile). 


Yio.  698.— Butlin's  incisions  for  extirpation  of  the  corvical  lymphatics. 

For  partial  or  complete  removal  of  the  tongue,  various  methods  are 

in  use.  ^, 

Intrabuccal  Method  {Whitehead's  Operatioji,  1881).— The  tongue  is 
held  within  the  mouth  chiefly  by  the  frenum  and  the  anterior  pillars 
of  the  fauces.  If  these,  and  the  mucous  membrane  between  the 
tongue  and  the  mandible,  are  divided,  the  tongue  can  be  pulled  far 
out  of  the  mouth  (Roux,  1839).  In  growths  involving  only  a  small 
area  on  the  anterior  part,  it  usually  is  sufficient  to  remove  the  half 
of  the  tongue  diseased.  A  stout  linen  ligature  is  passed  through  the 
tip  of  the  tongue  on  the  healthy  side,  and  after  dividing  the  frenum 
and  the  mucous  membrane  on  the  diseased  side  of  the  floor  of  the 
mouth,  the  tongue  is  split  down  the  middle  by  scissors,  and  the  half 
to  be  removed  is  cut  squarely  across  at  least  three-quarters  of  an  inch 
behind  the  growth.  The  arteries  are  caught  as  they  are  cut :  the  lingual 
in  the  floor  of  the  mouth,  and  the  dorsalis  linguae  as  it  spurts  from  the 
stump.  The^'  are  tied  securely,  and  the  mucosa  of  the  remaining  half 
of  the  tongue  is  sutured  to  the  border  left  attached  to  the  mandible 
of  the  diseased  side.  If  the  entire  tongue  is  to  be  removed  by  this 
method,  each  half  of  the  tongue  is  removed  separately,  as  above 
described,  the  precaution  being  taken  to  secure  the  stump  of  the 
tongue  (glosso-epiglottidean  fold)  by  a  strong  linen  ligature  before  the 
second  half  is  removed.  This  ligature  is  useful  in  controlling  hemor- 
rhage, and  should  be  left  hanging  out  of  the  mouth  for  a  few  days, 
to  aid  in  overcoming  any  respiratory  difficulty. 

Method  hi/   Division  of  the  Symphysis  Menti.— This  operation  was 
introduced  by  Sedillot  (1844),  and  a  few  years  later  by  Syme.    Kocher 


()54  SiRdEHY   OF    THE   FACE,   MOLTII,   AND   NECK 

has  recently  adopted  it  as  his  normal  method.  It  is  used  for  removal 
of  the  entire  tongue  in  cases  where  the  floor  of  the  mouth  is  involved. 
The  lower  lip  is  divided  in  the  mid-line,  and  this  incision  is  carried 
down  to  the  hyoid  bone.  The  mandible  is  then  drilled  in  two  places 
on  each  side  of  the  mid-line,  to  facilitate  its  subsequent  wiring.  The 
symphysis  is  then  sawed  through,  and  the  halves  of  the  mandible 
are  separated.  Rough  handling  may  cause  a  fracture.  The  mucous 
membrane  on  the  floor  of  the  mouth  is  then  divided,  the  lingual  arteries 
are  caught  and  tied,  and  the  tongue,  with  as  much  of  the  floor  of  the 
mouth  as  necessary,  is  removed  in  one  mass.  The  stump,  with  the 
two  spurting  dorsales  lingua^  arteries,  is  treated  as  in  Whitehead's 
method,  over  which  this  operation  presents  few  advantages.  The 
exposure  is  not  wvy  much  better,  the  wound  left  is  very  prone  to 
infection,  and  the  jaw  frequently  fails  to  unite  solidly. 

Suhnia.villari/  Method.'^. — Regnoli  (1S3S)  exposed  the  tongue  by  a 
transverse  suprahyoid  incision,  for  removal  of  its  anterior  portion. 
For  a  growth  confined  to  the  base  of  the  tongue,  Kocher  has  adopted 
subhyoid  pharyngotomy.  For  tumors  at  the  side  of  the  tongue  invading 
the  floor  of  the  mouth,  Kocher  formerly  employed  an  incision  from  the 
symphysis  downward,  then  backward,  and  finally  upward  to  the 
mastoid;  this  is  still  known  as  Kocher' s  method.  The  skin-flap  thus 
outlined  is  turned  upward,  the  lymphatic  tissue  in  the  upper  part 
of  the  neck  is  removed,  and  the  external  carotid  artery  and  facial 
vein  are  ligated  if  necessary.  The  submaxillary  salivary  gland  is 
removed,  because  though  seldom  itself  invaded,  there  usually  are 
lymph  nodes  imbedded  in  its  lobules.  The  mouth  is  opened  at  the 
posterior  border  of  the  mylohyoid  muscle,  and  the  attachments  of 
the  tongue  to  the  hyoid  bone  are  severed.  Then  the  tongue  is  drawn 
down  into  the  wound,  and  its  base  is  cut  across.  The  wound  must 
be  freely  drained,  by  a  large  tube  passing  from  the  buccal  cavity  out 
at  the  incision  in  the  neck.  Langenbeck\s  Method  (1875)  consists  in 
making  an  incision  from  the  angle  of  the  mouth  downward  to  the 
level  of  the  thyroid  cartilage,  with  division  of  the  mandible  between 
the  first  and  second  molar  teeth,  thus  approaching  the  tongue  from 
the  side. 

When  it  is  necessary  to  excise  a  portion  of  the  tiinndible  along  with 
the  tongue  and  the  floor  of  the  mouth,  Oespiand  Bastianelli's  modifi- 
cation (1S90)  of  Langenbeck's  method  is  to  be  preferred.  The  lower 
lip  is  divided  in  the  median  line,  and  the  incision  is  carried  backward 
to  the  mastoid,  well  below  the  jaw,  as  in  Kocher's  method.  After 
clearing  the  upper  cervical  region,  and  ligating  the  external  carotid 
artery  and  the  facial  vein,  the  mandible  is  divided  well  in  front  and 
behind  the  growth,  and  the  tongue  and  floor  of  the  mouth  are  removed 
in  one  piece  with  it.  A  similar  operation  gives  the  best  exposure  for 
cancer  arising  in  or  involving  secondarily  the  floor  of  the  mouth, 
whether  or  not  excision  of  the  mandible  is  required.  To  remedy 
the  defect  in  the  floor  of  the  mouth,  the  remaining  half  of  the  tongue 
(if  it  has  not  required  removal)  may  be  split  parallel  with  the  floor  of 


OI'I'Jh'ATlOXS  ().\    TlIK  MR  SINUSES  <)')5 

tlif  iiioutli,  and  thus  cuii  l)c  sj)R'a(l  out  lar  rnou^li  to  \)v  sutured  to 
the  mucous  nienihrane  of  the  cheek,  above  the  alveolus  (v,  Eiselsberg, 
1«)()4;  W.  Bartlctt.  I!)()7).  If  the  niaudihle  is  not  already  edentulous 
the  teeti)  may  he  pnllcil,  and  any  unicous  memhrane  still  adherent 
to  the  jaw  may  he  dissected  away. 

After  removal  of  the  tongue  the  patient  still  can  make  himself 
understood,  and  swallowinji;  is  not  interfered  with. 

Pallidflrc  Oprration.s  sometimes  are  possible,  even  when  the  disea.se 
is  too  far  advanced  to  ati'ord  hoj)e  of  cure.  The  most  important  of 
these  methods  is  extirpation  of  the  external  carotid  arteries,  on  l)oth 
sides,  as  introduced  by  Dawbarn  (lOO.'i),  to  effect  starvation  of  the 
lingual  growth.  Or  they  may  be  injected  with  paraffin.  These 
methods  are  not  aj)plical)le  to  cases  where  the  lymphatic  in\'olve- 
ment  over-shadows  the  original  growth.  The  use  of  radium  emana- 
tion and  of  the  .c-ray  may  be  valuable  in  allaying  pain,  and  in 
diminishing  fetor  and  secretion. 

OPERATIONS  ON  THE  AIR  SINUSES. 

The  air  sinuses  are  mucous-lined  cavities  draining  into  the  nasal 
passages,  and  like  the  middle  ear  are  prone  to  become  infected  when 
their  drainage  is  obstructed.  The  cure  of  adenoids,  deflected  septum, 
hyi)ertrophied  turbinates,  and  other  seemingly  mimjr  conditions, 
therefore,  becomes  important  as  a  prophylactic  against  more  serious 
ailments.  Acute  infections  of  these  accessory  sinuses  usually  are 
treated  successfully  by  the  rhinologist  by  the  intranasal  route,  and -are 
by  no  means  so  important  surgically  as  chronic  infections,  which 
require  radical  operation  for  their  relief.  These  chronic  lesions  may 
consist  merely  of  empyema  of  the  sinus  affected,  or  there  ma\'  be 
exuberant  (jranidation  tissue,  or  even  mucous  polypi.  As  all  these 
afi'ections  are  rightly  considered  a  part  of  the  specialty  of  nose  and 
throat  disea.ses,  it  seems  inexpedient  to  do  more  here  than  outline  in 
the  briefest  possible  manner  the  nature  of  the  operations  at  present 
employed  in  their  treatment.  An  acute  exacerbation  of  a  chronic 
lesion  may  occur  at  any  time,  and  may  be  quickly  fatal,  especially  in 
the  case  of  the  frontal,  ethmoidal,  and  sphenoidal  sinuses,  unless 
immediate  adequate  drainage  is  provided. 

The  diagnosis  of  chronic  sinusitis  is  not  always  easy,  l)ut  depends 
in  large  measure  upon  persistent  discharge  of  pus,  found  by  intranasal 
examination  to  enter  the  nasal  passages  in  the  region  where  the 
suspected  sinus  normally  drains.  There  are  in  addition,  when  drain- 
age is  inefficient,  usually  headache  and  localized  tenderness.  In 
ethmoidal  disease  the  pain  usually  is  referred  to  the  bridge  of  the  nose 
and  the  eyeball;  in  sphenoidal  sinusitis  it  usually  is  between  the  eyes 
and  in  the  occipital  region;  in  frontal  sinusitis  the  pain  and  tenderness 
are  localized  to  the  region  above  the  root  of  the  nose  and  the  inner 
margin  of  the  orbital  cavity,  and  occasionally  the  pus  perforates 
anteriorly  and  forms  an  abscess  at  the  root  of  the  nose;  in  maxillary 


05G  SURGERY  OF  THE  FACE,  MOUTH,   AND  NECK 

siunsUis  the  i)ain  may  l)e  referred  to  the  teeth,  the  nose,  or  all  over 
the  head,  but  tenderness  usually  is  localized  to  the  maxillary  bone. 
As  a  preliminary  to  all  these  operations,  preparation  of  the  nasal 
passajjes  by  a  course  of  conservative  treatment  is  essential  to  success. 
This  usually  conii)rises  removal  of  the  anterior  portion  of  the  middle 
turbinate  bone  which  almost  invariably  is  thickened  and  interferes 
with  intranasal  drainage.  In  cases  of  patients  acutely  ill  it  often  is 
better  to  do  an  operation  which  is  incomplete  from  the  specialist's 
standpoint,  consisting  merely  in  securing  adequate  drainage  by  the 
most  accessible  route,  and  to  postpone  the  ideal  radical  operation  to 
another  occasion,  as  in  the  parallel  cases  of  acute  mastoiditis  (p.  632). 
Drainage  tubes  or  gauze,  employed  in  these  nasal  operations  never 
should  be  allowed  to  remain  in  place  more  than  forty-eight  hours. 
Careful  after-treatment,  preferably-  conducted  by  a  rhinologist,  is 
necessary  to  complete  the  cure. 

The  maxillary  antrum  communicates  with  the  nasal  cavity  through 
its  middle  meatus,  and  the  opening  is  some  distance  above  the  floor 
of  the  sinus  so  that  drainage  is  very  imperfect.  Infection  may  follow 
nasal  disease  or  be  due  to  extension  upward  from  a  carious  tooth. 
When  conservative  measures  fail,  the  surgeon  may  break  through  the 
outer  wall  of  the  nasal  fossa,  in  the  inferior  meatus,  thus  establishing 
drainage  at  the  level  of  the  floor  of  the  antrum.  This  may  be  done  in 
emergency  by  firm  pressure  with  the  blunt  ends  of  the  blades  of  scissors 
curved  on  the  flat.  Usually  it  is  preferable  to  open  the  maxillary  sinus 
by  gouge  and  mallet  through  the  canine  fossa,  after  incising  and 
reflecting  the  mucous  membrane  and  periosteum.  A  large  opening 
in  the  outer  wall  of  the  sinus  should  be  made,  and  its  cavity  should 
be  cleared  of  polypi,  necrotic  bone,  etc.  Then  the  inner  wall  of  the 
sinus  is  broken  down  as  far  as  the  level  of  its  floor,  working  across  its 
cavity.  The  nasal  mucous  membrane  is  preserved,  is  formed  into  a 
flap  attached  along  the  floor  of  the  nose,  and  is  turned  outward  to 
cover  the  floor  of  the  maxillary  sinus,  which  is  thus  freely  drained  into 
the  inferior  meatus  of  the  nose.  This  mucous  flap  is  held  in  place  by 
packing  introduced  from  the  nasal  cavity,  and  the  incision  in  the 
alveolar  tissues  is  closed  by  suture. 

The  frontal  sinus  is  readil}'  exposed  by  applying  a  small  trephine 
just  to  one  side  of  the  glabella.  As  the  size  of  these  sinuses  is  extremely 
A'ariable,  not  only  in  different  individuals,  but  also  on  the  two  sides 
of  the  same  individual,  the  surgeon  always  should  make  an  opening 
which  is  small  and  close  to  the  root  of  the  nose,  so  as  to  run  no  danger 
of  entering  the  cranial  cavity.  This  opening  may  then  be  enlarged 
with  gouge  or  rongeur.  A  tract  for  drainage  into  the  middle  meatus 
of  the  nose  can  be  made  by  enlarging  the  infundibulum  with  curette. 
Such  drainage,  by  a  tube  passed  from  the  inner  angle  of  the  frontal 
incision  down  into  the  nose,  is  sufficient  in  emergency.  Killian's 
operation,  described  below,  is  preferable  as  a  method  of  radical  cure. 

The  anterior  ethmoidal  cells  frecpiently  are  diseased  along  with  the 
frontal  sinus,  as  they  usually  drain  into  the  upper  part  of  the  infun- 


SURGERY  OF  THE  JAWS  057 

dil)iiluni;  iiiid  tlu-y  ;irc  best  cviicuatrd  across  tlio  opcm-d  t'ruiital  sinus. 
Tlio  middle  and  posterior  ethmoidal  cells  drain  into  the  middle  meatus 
and  till'  superior  meatus,  respectively.  They  may  he  reached  hy  resec- 
tion of  the  OS  planum,  after  exposing,'  the  inner  wall  of  the  orbit. 
There  may  be  a  fistula  in  this  situation,  or  even  an  abscess  between 
the  OS  plaiuim  and  the  eye-ball.  Drainage  into  the  nasal  cavity  and 
from  the  i-xternal  wound  is  provided  for.  For  radical  cure,  Killian's 
oi)eration  is  preferable. 

The  sphenoidal  sinus  seldom  can  be  drained  elVectively  by  the  intra- 
nasal route,  and  as  the  ethmoidal  and  frontal  sinuses  frequently  are 
involved  also,  the  method  of  treatment  for  radical  cure  usually 
employed  now  is  that  known  as  Killian's  Operation  (1902),  which 
involves  an  approach  across  the  frontal  sinus.  This  includes  removal 
of  the  anterior  wall  of  the  frontal  sinus  and  of  its  floor  (the  roof  of  the 
iimer  part  of  the  orbit),  leaving  a  bridge  of  bone  (supra-orbital  ridge) 
l)etween  these  two  openings  to  support  the  soft  parts  when  sutured 
and  thus  prevent  deformity.  After  evacuating  the  frontal  sinus,  and 
thoroughly  exposing  all  its  angles,  the  frontal  process  of  the  superior 
maxilla  is  removed.  (This  should  be  done  without  injury  to  the 
mucosa  of  the  nasal  cavity,  which  is  to  be  preserved  as  a  flap  to  line 
the  excavated  frontal  sinus  and  establish  a  free  communication 
between  this  cavity  and  the  nose.)  The  ethmoid  cells  which  are  thus 
exposed  are  then  cleaned  away,  and  the  anterior  wall  of  the  sphenoidal 
sinus  is  removed  by  gouge  or  gouge  forceps.  Removal  of  part  of  the 
nasal  bone  of  the"  side  affected  may  be  necessary  to  secure  better 
exposure.  The  flap  of  nasal  mucosa  finally  is  turned  outward  across 
the  lower  wall  of  the  large  cavity,  and  this  is  Ughtly  packed  with  gauze 
which  emerges  into  the  nasal  fossa.  The  external  wound  is  then 
completely  sutured. 


SURGERY  OF  THE  JAWS. 

Alveolar  Abscess.— Aheolar  abscess  almost  always  is  secondary 
to  dental  disease.  Before  the  stage  of  suppuration,  peridental  inflam- 
mation is  denoted  by  tenderness,  which  usually  is  relieved  by  firm 
pressure  on  the  gum,  accompanied  by  moderate  swelHng.  At  this 
stage  proper  disinfection  of  the  root  canals  of  the  teeth,  which  are 
infected  from  the  cavity  in  the  crown,  usually  causes  arrest  of  the  pro- 
cess. Later  the  entire  side  of  the  jaw  may  be  swollen,  and  tenderness 
is  exquisite.  Sometimes  the  pus  escapes  at  the  side  of  the  tooth,  but 
in  many  cases  it  spreads  beneath  the  periosteum  of  the  jaw,  and 
unless  promptly  evacuated,  osteomyelitis  and  necrosis  may  result,  or 
in  the  upper  jaw%  involvement  of  the  maxillary  sinus.  Occasionally 
the  pus  breaks  through  the  skin  below  the  l)ody  of  the  mandible 
(Fig.  ()99),  or  will  form  an  abscess  in  the  cheek  (Fig.  700).  Secondary 
infection  of  the  salivary  glands  or  of  the  cervical  lymph  nodes  may 
occur. 
42 


658 


SURGERY  OF   THE  FACE,   MOUTH,   A\D  XECK 


Treatment. — Early  free  incision  of  the  alveolar  border,  down  to  the 
bone,  followed  by  detergent  mouth  washes  usually  is  promptly  curative, 
and  even  if  no  pus  is  found  this  incision  quickly  relieves  pain  and 
markediv  accelerates  recoverv. 


Fig.  699. — Alveolar  abscess  of  lower 
jaw,  pointing  over  body  of  mandible. 
Four  days  after  extraction  of  tooth. 
Episcopal  Hospital. 


Fig.  700. — Abscess  of  left  cheek,  fol- 
lowing pulling  of  teeth  on  upper  and 
lower  jaw.  thirteen  days  previously. 
Episcopal  Hospital. 


Acute  Osteomyelitis  of  the  jaws  is  not  common  even  in  the  mandible, 
and  in  the  maxilla  is  decidedly  rare.  The  general  septic  symptoms 
render  differentiation  from  alveolar  abscess  easy. 

Treatment. — Treatment  consists  in  free  incision,  both  inside  and 
outside  the  mouth.  The  inflammation  may  be  confined  to  the  alveolar 
border,  but  it  is  better  to  open  the  body  of  the  jaw  by  trephine  or  gouge 
if  there  is  any  doubt  as  to  the  limits  of  the  disease.  Free  drainage 
is  the  most  essential  factor. 

Necrosis  of  the  Jaws  affects  the  mandible  in  most  cases,  and  follows 
acute  osteomyelitis,  or  may  be  due  to  phosphorus  poisoning,  with 
subacute  or  chronic  onset.  In  the  latter  instance  the  disease  seldom 
appears  until  the  patient  has  been  working  in  phosphorus  for  several 
years,  and  it  may  not  appear  for  several  years  after  the  patient  has 
quit  his  work  in  phosphorus.  Phosphorus  poisoning  produces  changes 
of  a  chronic  ossifying  nature  in  the  periosteum  in  all  parts  of  the 
body,  resulting  in  increased  density  of  the  bone,  decrease  in  the 
size  of  the  marrow  cavity,  and  lessened  circulation.  These  changes 
are  particularly  marked  in  the  mandible.  If  secondary  infection  does 
not  intervene,  as  in  the  mandible  it  usually  does  from  carious  teeth, 
the  later  stages  of  the  process  (rarefaction  and  pathological  fracture) 
are  seen.  Workers  in  phosphorus  should  have  their  teeth  inspected 
and  cleaned  by  a  competent  dentist,  at  frequent  intervals.    Necrosis 


SURGERY  OF   THE  JAWS 


659 


of  tilt'  jaws  ocfasioiially  results  from  the  constitutional  effects  of 
arsenic  jxiiftoninc/,  or  from  mercurial  stomatitis. 

Treatment. — Treatment  consists  in  providing;  free  drainage  hy 
incision  of  the  soft  parts  and  involucrum,  when  the  latter  is  j)resent. 
(ireat  conservatism  should  be  exercised  in  extraction  of  scfjuestra. 
It  is  best  to  wait  initil  they  are  freely  movable  by  probes  introduced 
through  nei«;hboring  cloacae,  and  until  the  involucrum  has  developed 
sufficiently  to  maintain  the  form  of  the  jaw.  Though  the  teeth 
usually  are  lost,  the  ultimate  outcome  as  regards  function  usually 
is  satisfactory. 

Ankylosis  of  the  Temporo-maxillary  Joint  may  be  unilateral  or 
bilateral,  but  even  unilateral  involvement  renders  the  jaw  immovable. 
The  condition  may  result  from 
various  forms  of  arthritis  or  from 
fracture  of  the  condyle;  or  false 
ankylosis  may  occur  from  peri- 
articular contractures,  due  to  cica- 
trices from  burns,  etc.  If  the 
ankylosis  occurs  before  full  de- 
velopment of  the  mandible,  retrog- 
nathism,  or  micrognathy  is  the 
result  (Fig.  701),  from  loss  of 
function.  In  unilateral  ankylosis 
the  affected  side  of  the  mandible 
seems  smaller  than  the  sound  side, 
but  stands  out  normally  from  the 
neck,  whereas  the  healthy  side 
appears  flattened;  the  chin  usuall\' 
is  deviated  toward  the  affected 
side  (Kirstein,  1910). 

Treatment. — Some  form  of  arthro- 
plasty (p.  471)  is  necessary  to  re- 
store motion.  The  joint  is  best  ex- 
posed by  turning  down  from  above 
a  skin-flap  with  temporary  resec- 
tion  of    the   zygoma    (Lilienthal, 

191 1  J.  The  condyle  of  the  mandible  is  then  excised,  and  a  flap  turned  in 
from  the  temporal  muscle  or  masseter.  By  turning  down  the  zygoma, 
with  attached  masseter  muscle,  any  damage  to  the  facial  nerve, 
parotid  gland,  and  duct,  is  avoided.  The  periosteal  insertion  of  the 
external  pterygoid  muscle  should  be  preserved.  The  older  operations 
of  resection  of  a  wedge  from  the  body  of  the  mandible  in  front  of  the 
angle  seldom  succeeded  in  restoring  permanent  motion.  For  false 
ankylosis  from  cicatricial  contractures  a  plastic  operation  is  necessary. 
Murphy  (1913)  uses  a  flap  of  mucous  membrane  from  the  hard  palate. 
The  mandible  may  be  lengthened  by  osteoplastic  operation  on  both 
sides,  dividing  the  body  in  sigmoid  fashion  and  sliding  the  lower 
segment  forward. 


Fig.  701. — Retrognathism  from  anky- 
losis of  jaw  due  to  post-scarlatinal  arthri- 
tis in  infancy.  Xow  eight  j-ears  old. 
Orthopaedic  Hospital. 


660 


SURGERY  OF   THE  FACE,  MOUTH,  AND  NECK 


Facial  Hemiatrophy  is  a  very  rare  condition  of  obscure  origin,  but 
one  whose  existence  should  be  known  to  the  surgeon,  for  diagnostic 
purposes  (Fig.  702).    The  atrophy  afi'ects  bones  as  well  as  soft  parts. 

It  may  be  associated  with  neuritis 
of  the  trigeminal  nerve,  but  usually 
is  not  painful.  Neurologists  treat 
it  by  electric  currents  and  general 
hygienic  measures. 

Tumors  of  the  Jaw. — These  may 
arise  from  the  alveolar  border  or 
from  the  body  of  the  bone. 

Tumors  of  the  Alveolar  Border. 
— There  are  three  of  these  alveolar 
growths  of  considerable  frequency: 
Epulis,  Ossifying  Periosteitis,  and 
Carcinoma. 

1.  Epulis. — Epulis,  a  connective 
tissue  tumor,  is  the  most  frequent 
growth  of  the  alveolus.  Pathologic- 
ally it  is  either  (a)  a  fibroma  or  an 
angeio-fibroma,  or  (b)  a  tumor  con- 
taining giant  cells,  resembling  a 
myeloma  or  myeloid  sarcoma.  This 
appears  to  be  the  only  region  in 
the  body  where  giant  cells  spring 
from  periosteum.  Epulis  seems 
to  be  more  nearly  related  to  in- 
flammatory processes  than  to  true  neoplasms.  The  giant-celled  form 
often  arises  above  an  old  root  or  beside  a  decayed  tooth,  and  is  red- 
dish brown  in  color;  but  the  fibrous  form  may  occur  where  the  teeth 
appear  normal,  and  is  whiter  in  color.  Epulis  is  painless,  but  in 
spite  of  this  fact  often  has  been  mistaken  for  an  alveolar  abscess.  It 
occurs  in  children  or  young  adults,  is  soft  and  elastic,  but  does  not 
fluctuate.  Ulceration  may  occur  eventually,  but  is  very  long  delayed. 
Treatment. — Treatment  consists  in  local  extirpation  by  knife  and 
gouge  forceps,  through  healthy  tissues.  The  raw  surface  left  should  be 
seared  with  the  actual  cautery.  Recurrence  may  take  place  if  the 
surgeon  is  too  conservative.  Yet  even  after  repeated  recurrence  no 
metastasis  occurs.  It  never  is  necessary  to  excise  the  whole  thick- 
ness of  the  bone;  removal  of  the  portion  of  the  alveolus  afi'ected  is 
sufficient. 

2.  Ossifying  Periosteitis  forms  a  diffuse  bony  enlargement  of  the 
alveolus.  It  may  be  due  to  chronic  infection  (as  pyorrhea  alveolaris). 
Subperiosteal  resection  may  be  done,  without  fear  of  recurrence. 

3.  Carcinoma. — Carcinoma  is  commoner  on  the  upper  (Fig.  703)  than 
the  lower  jaw  (Fig.  704).  It  is  sufficiently  distinguished  from  epulis 
by  its  occurrence  only  in  older  patients,  by  its  early  ulceration,  the 
marked   induration   of  the  borders  of  the  ulcer,  and  the  ultimate 


Fig.  702. — Left  facial  hemiatrophy. 
Male  twenty-six  years  old.  Duration 
ten  months.  No  injury,  but  he  was  a 
"boxer"  and  deformity  was  mistaken 
for  that  due  to  impacted  and  united 
fracture  of  ascending  ramus  of  lower 
jaw.  Notice  over-lapping  of  teeth. 
Episcopal  Hospital. 


SURCERY  OF  THE  J.IU'.S 


GGl 


involvemont  of  the  lymi)li  muies.  Extirpiition,  tojrcthcr  with  wide 
excision  of  the  lymphatics  of  the  same  si(h'  as  the  lesion,  is  the  i)roi)er 
treatment. 


Fig.  7U::i. — Lareiiioiiia  oi  uiipcr  jaw.  Age 
seventy-three  years;  duration  sLx  months, 
now  inoperable.  Was  struck  on  this  side  of 
mouth  one  year  ago  by  handle  of  "release" 
while  running  engine.    Episcopal  Hospital. 


Fig.  704. — Recurrent  carcinoma  of 
inferior  maxilla.  Partial  excision  of 
mandible  in  September,  1906.  Pho- 
tograph March  1908.  Now  inoperable. 
(Dr.  H.  C.  Deaver's  case.)  Episcopal 
Hospital. 


Tumors  of  the  Body  of  the  Jaw.— Some  of  these  are  benign,  and 
some  are  malignant.  Among  the  former  are  dentigerous  cysts,  espe- 
cially the  adamantinoma.  These  were  discussed  at  p.  112.  Of  the 
malignant  tumors  {sarcomas)  there  are  various  forms.  Until  recently 
the  giant-celled  form  of  epulis,  affecting  the  alveolus,  was  classed  as 
a  sarcoma.  True  sarcoma  may  affect  the  body  of  either  the  upper 
or  lower  jaw.  Usually  it  is  periosteal  in  origin,  and  grows  as  a  firm  or 
even  a  bony  tumor.  It  does  not  present  egg-shell  crackling,  which  is 
common  in  the  admantinoma,  and  occurs  in  older  patients  than  those 
in  whom  dentigerous  cysts  usually  are  seen.  According  to  Bloodgood 
sarcoma  of  the  lower  jaw  in  front  of  the  angle  usually  is  of  a  less  malig- 
nant nature  than  the  forms  which  occur  at  the  angle  and  rapidly  invade 
the  ramus.  The  former  (less  malignant)  growths  are  "mixed  sar- 
comas," that  is,  partly  bony,  fibrous,  or  myxomatous,  and  are  rare 
after  the  age  of  twenty-five  years.  The  more  malignant  varieties, 
which  are  rare  before  the  age  of  twenty-five  years,  are  spindle-  and 
round-celled  sarcomas.  These  latter  quickly  invade  the  soft  parts, 
extending  in  the  upper  jaw  to  the  antrum  (where,  indeed,  they  may 
originate),  to  the  orbit,  and  to  the  temporo-maxillary  fossa;  and  in 
the  lower  jaw  invading  the  pharynx  and  soft  structures  of  the  neck. 
The  differential  diagnosis  is  best  made  from  an  excised  specimen. 


662 


SURGERY  OF  THE  FACE,  MOUTH,  AND  NECK 


Treatir.ent. — In  the  less  malignant  forms  of  sarcoma,  the  surgeon 
aims  to  remove  the  entire  growth,  with  a  small  margin  of  healthy 
tissue  on  all  sides.  In  the  lower  jaw  this  usually  necessitates  a  resec- 
tion of  the  entire  thickness  of  the  bone,  though  very  occasionally  the 
ah'eolar  border  may  be  left  as  a  splint  to  maintain  the  form  of  the  bone. 
In  the  upper  jaw  it  usually  is  possible  to  preserve  the  or})ital  jjlate, 
and  often  the  hard  palate  also.  It  is  doubtful  whether  any  operation, 
even  the  most  radical,  is  of  any  use  whatever  in  the  more  malignant 
forms  of  sarcoma. 

Excision  of  the  Superior  Maxilla. — The  typical  operation^  though 
seldom  done  at  present  for  tumors  arising  in  the  maxilla  itself,  some- 
times is  required  as  a  preliminary  to  the 
removal  of  growths  in  the  naso-pharynx. 
Preliminary  ligation  of  the  external  carotid 
artery  is  advisable  if  the  operation  is  for 
exposure  of  such  a  tumor.  The  incision 
shown  in  Fig.  705,  enters  the  nostril  and 
outlines  a  flap  which  is  reflected  outward, 
the  knife  being  kept  close  to  the  peri- 
osteum. The  mucous  membrane  of  the 
hard  palate  is  divided  in  the  median  line, 
and  the  attachment  of  the  soft  palate  to 
the  bone  severed  transversely.  The  mu- 
cous membrane  of  the  gingi^'o-labial  fold 
is  divided  clear  of  the  disease,  and  that  in 
the  floor  of  the  nose  is  divided  in  the 
median  line.  After  extraction  of  the  cen- 
tral incisor  tooth  on  the  involved  side,  the  alveolus  and  palate  are 
divided  by  a  phalangeal  saw  (Fig.  139,  6),  introduced  through  the 
nostril.  The  tissues  of  the  orbit  are  then  displaced  upward,  the  si)heno- 
maxillary  fissure  is  identified,  and  the  attachment  of  the  maxilla  to 
the  malar  bone  is  divided  wdth  saw.  Then  the  nasal  process  of  the 
maxilla  is  divided  from  orbital  to  nasal  cavit>%  and  the  bone  is  grasped 
in  lion-jawed  forceps  and  pulled  downward,  any  remaining  attachments, 
including  the  junction  of  the  pterygoid  processes  with  the  maxilla,  being 
severed  with  bone-cutting  forceps  or  chisel.  Hemorrhage  is  then  con- 
trolled, if  necessary  by  the  actual  cautery.  The  mucosa  of  the  cheek 
is  then  sutured  to  that  of  the  palate,  and  the  skin  wound  closed  with 
interrupted  sutures,  after  packing  it  loosely  with  iodoform  gauze,  which 
is  made  accessible  through  the  nostril.  Frequent  syringing  through  the 
nostril  or  any  opening  in  the  roof  of  the  mouth  is  required  during  con- 
valescence. Temporary  resection  of  the  superior  maxilla  is  done  by  the 
same  skin  incision,  but  the  flap  is  not  separated  from  the  bone;  this 
is  divided  as  above  described  except  at  its  malar  attachment,  which  is 
used  as  a  hinge,  after  fracture  by  leverage  outward. 

Excision  of  the  Inferior  Maxilla. — The  typical  operation  involves 
only  half  the  mandible.  An  incision  is  made  from  the  middle  of  the 
lower  lip  down  to  the  hyoid  bone,  and  from  this  point  back  as  far  as 


Fig.  705. — Fergusson's  incision 
for  excision  of  upper  jaw. 


SURGERY  OF  THE  TONSIL  AND  PHARYNX 


()()3 


the  aiifilo  of  tlu'  jaw,  thv  submaxillary  structures  arc  dissectcl  tree, 
and  the  soft  part's  arc  separati'd  from  the  outer  surface  of  the  bone, 
respecting,'  the  branches  of  the  facial  nerve,  but  liKatinf^  the  facial  and 
the  linunial  arteries  and  veins.     :\iost  of  the  external  surlace  ot  the 
ranms  is  thus  exposed.     The  symphysis  is  then  divided  with  saw  and 
the  structures  of  the  floor  of  the  mouth  cut  with  scissors,  from  before 
backward.      An  incision  is  then  made  alon^'  the  mucous  membrane 
on  each  side  of  the  ascending  ramus  of  the  jaw;  the  bone  is  forcibly 
depressed,  and  the  insertion  of  the  temporal  muscle  into  the  coronoid 
I)rocess  is  divided  with  scissors.    The  jaw  is  then  turned  somewhat 
outward,  and    the  ptcryj;-oid    muscles  cut  dose  to  their  insertions. 
The  liiii^nial  nerve  should   be  preserved   if   i)()ssible,  but,  of   course, 
the  inferior  dental  must  be  sacrificed.    The  temporo-maxillary  joint 
mav  then  be  opened,  the  few^  remaining  attachments  severed,  and  the 
bone  removed.    After  careful  control  of  all  hemorrhage,  the  pterygoids 
are  sutured  to  the  masseter  muscle,  and  the  mucous  menil)rane  of  the 
cheek  united  to  that  of  the  floor  of  the  mouth.    Finally  the  skin 
wound   is  closed,    with   provision  for  drainage   externally.     Partial 
('.vci,v(»i  involves  removal  only  of  the  portion  of  bone  afl'ected,  after 
its  division  in  front  of  and  behind  the  growth. 

Prosthesis  after  Excision  of  the  Inferior  Maxillary  Bone.—U  the 
periosteum  can  be  preserved,  a  shell  of  bone  sufficient  to  prevent  exces- 
sive deformitv  may  be  formed  in  time.  While  the  wound  is  healmg 
the  remaining  portions  of  the  bone  should  be  held  in  proper  position 
bv  stout  silver  wire,  used  as  a  bridge  across  the  gap  left  b\-  excision 
of  the  diseased  portion.  A  sinus  usually  persists  until  the  wire  is 
remo^•ed,  but  bv  that  time  the  bone  may  be  sufficiently  firm.  Claude 
:\Iartin,  of  Lyons,  since  1878,  has  employed  after  excision  of  either 
upper  or  lower  jaw,  a  temporary  prosthesis  made  of  hard  rubber,  pre- 
viouslv  constructed  to  fit  into  the  contemplated  defect.  This  pros- 
thesis'is  riddled  with  channels,  and  though  it  is  implanted  into  the 
wound  through  the  buccal  aspect  (no  attempt  being  made  to  close 
an^'thing  but  the  skin),  the  wound  and  the  appliance  may  in  almost 
alf  cases  be  kept  clean  until  healing  occurs  by  irrigation  through 
its  numerous  channels.  When  healing  is  complete  a  permanent 
prosthesis  is  constructed. 

SURGERY  OF  THE  TONSIL  AND  PHARYNX. 

Peritonsillar  Abscess  or  Quinsy  usually  is  a  sequel  of  parenchy- 
matous am^■gdalitis.  The  systemic  symptoms  of  sepsis  may  be  marked. 
Localh-,  in  addition  to  the  signs  of  the  preceding  tonsillitis,  may  be 
observed  a  diffuse  swelling  of  the  soft  palate  at  the  upper  border  of 
the  tonsil.  At  no  time  is  a  distinct  sense  of  fluctuation  obtainable. 
Earlv  evacuation  is  the  only  satisfactory  treatment.  Thrust  a  grooved 
director  through  the  most  prominent  part  of  the  swelling  (usually 
through  the  soft  palate),  after  painting  it  with  10  per  cent,  cocain 
(Fig.  706).    The  tract  made  by  the  grooved  director  may  be  enlarged 


664 


SURGERY  OF   THE  FACE,   MOUTH,   AND  NECK 


Fig.  706. — Puncture  of  peritonsillar  abscess 
through  soft  palate. 


by  inserting  the  closed  points  of  a  pair  of  dressing  forceps,  and  with- 
drawing the  instrument  with  the  bla(h^s  ()})ened.  Tiic  reHef  is  innne- 
diate,  and  under  the  use  of  simple  alkaline  mouth  washes  con\al- 
escence   usually   is   established    in   twenty-four   to   thirty-six   hours. 

If  a  peritonsillar  abscess  is 
left  to  burst  of  itself,  it  may 
do  so  during  sleep,  and  has 
caused  death  from  suffoca- 
tion. In  very  young  children 
it  is  better  to  open  it  in  the 
head-low  position. 

Malignant  Tumors  of  the 
Tonsil.  —  Either  carcinoma 
or  sarcoma  may  occur  in  the 
tonsil .  Diagnosis  is  not  easy. 
Any  unilateral  tonsillar  en- 
largement in  an  adult  should 
be  regarded  with  suspicion. 
The  possibility  of  syphilitic 
lesions  of  the  tonsil  (chan- 
cre and  ulcerated  gumma) 
should  be  kept  in  mind,  and 
their  presence  excluded  by  the  history  of  the  case,  the  existence  of 
evidences,  past  or  present,  of  the  disease  elsewhere  in  the  body;  as 
well  as  by  the  use  of  laboratory  and  therapeutic  tests.  In  most  cases 
a  specimen  of  the  growth  should  be  excised  for  microscopic  study. 
In  carcinoma  the  diagnosis  usually  is  easily  made  by  this  means, 
but  in  sarcoma  the  histological  picture  may  not  be  convincing. 

Symptoms. — The  symptoms  are  chiefly  those  of  obstruction,  in 
sarcoma,  with  pain  on  deglutition;  the  lymph  nodes  seldom  become 
enlarged  until  late  in  the  disease,  after  ulceration  has  occurred. 
Local  extension  to  the  palate  and  pharynx  is  much  more  common  in 
carcinoma,  and  in  this  affection  the  submaxillary  and  deep  cervical 
lymph  nodes  are  involved  early,  though  not  palpably  so  for  a  number 
of  weeks. 

Treatment. — If  the  diagnosis  is  made  very  early  in  the  disease, 
by  means  of  microscopic  study,  it  may  be  possible  to  enucleate  the 
tonsil  from  within  the  mouth.  Usually,  however,  and  particularly 
in  the  case  of  carcinoma,  the  growth  should  be  approached  from  the 
neck.  In  lateral  'pharyncjoiomy  an  incision  is  made  from  the  mastoid 
well  forward  under  the  body  of  the  jaw;  after  clearing  the  submaxil- 
lary and  cervical  regions,  the  facial  artery  is  ligated  close  to  its  origin, 
so  as  to  control  its  tonsillar  and  ascending  palatine  branches;  the  wall 
of  the  pharynx  is  incised  on  a  sound  introduced  through  the  mouth, 
and  the  diseased  area  excised  with  scissors.  Temporary  resection  of 
the  mandible  may  be  requisite.  Approach  to  the  tonsil,  the  epiglottis, 
and  the  pharynx  may  also  be  gained  by  suprahyoid  pharyngotomy 
(Jeremitsch,  1895;  von  Hacker,  1906);  in  this  operation  a  transverse 


SURCERY  OF  THE  MR  PASSAGES  005 

incision,  coiwi^N  t'onvard,  and  al>(>ut  throe  or  four  inches  I()nf,^  is  niach' 
uhovc  the  hyoid  hone,  and  all  tlie  inusck'S  passing  ujjward  from  tills 
bone  are  divided,  inchiding  both  genio-hyoids,  the  mylo-hyoid. 
genio-hyot;"lossus,  and  hyo-<j;h)ssns;  sometimes  also  the  stylo-liyoid 
and  anterior  helly  of  the  (Hgastric  on  the  side  of  tiie  lesion.  Enon<i,h 
tissue  should  be  left  attached  to  the  hyoid  bone  to  facilitate  subse- 
quent suture.  By  hyperextension  of  the  neck,  and  pulling  the  chin 
upward,  wide  exposure  of  the  base  of  the  tongue  and  the  lateral  pharyn- 
geal walls  is  secured.  Usually  the  facial  and  lingual  arteries  on  the 
more  diseased  side  must  be  ligated;  the  liy])oglossal  nerve  should  be 
preserved  if  possible.  Subhyoid  pharymjuioiny  (\'idal  de  Cassis,  1820; 
Sklifosovsky,  1802)  is  a  somewhat  similar  operation,  but  there  is  more 
danger  of  injuring  the  su])erior  laryngeal  nerve,  without  compensating 
advantages.  When  the  malignant  growth  has  been  excised,  the  severed 
cer^'ical  tissues  are  carefully  re-united  by  many  rows  of  buried  sutures, 
and  the  wound  is  freely  drained.  These  operations  are  dangerous, 
seldom  employed,  and  difficult  even  for  skilled  operators  with  accu- 
rate anatomical  knowledge. 

If  the  case  is  inoperable,  palliative  measures,  such  as  the  "  starva- 
tion" method  of  Dawbarn  (p.  055),  may  be  tried,  with  the  use  of  the 
x-ray,  and,  in  the  case  of  sarcoma,  of  Coley's  fluid. 

Tumors  of  the  Naso-pharynx.- — These  usually  are  soft  fibromas, 
occur  in  young  adults  from  fifteen  to  twenty-five  years  of  age,  and  in 
many  cases  assume  a  character  which  clinically  is  malignant,  though 
microscopical  examination  rarely  shows  a  typical  sarcoma.  They 
spring  from  the  submucous  tissues  at  the  base  of  the  skull,  and  grow 
into  the  nasal  passages,  invade  the  maxillary  sinus,  the  orbit,  the 
temporal  fossa,  and  may  open  even  the  cranial  cavity.  Occasionally 
they  seem  to  spring  from  the  antrum  and  grow  backward  into  the 
naso-pharynx.  Unless  removed,  death  is  practically  certain  from 
obstruction  to  respiration  and  deglutition.  The  growth  is  apt  to 
recur  after  partial  removal,  and  complete  extirpation  is  a  serious  and 
often  a  bloody  operation,  demanding  usually  excision  of  the  superior 
maxilla  (p.  002)  to  gain  access  to  the  growth,  even  if  this  bone  is  not 
itself  invaded  by  the  disease.  Preliminary  ligation  of  the  external 
carotid  artery  is  advisable,  and  the  actual  cautery  may  be  required 
to  check  the  bleeding  even  after  this  precaution. 

SURGERY  OF  THE  AIR  PASSAGES. 

Foreign  Bodies. — Foreign  bodies  are  especially  apt  to  enter  the 
larynx,  trachea,  or  bronchial  tubes  in  young  children,  wdio  thoughtlessly 
place  various  objects  in  the  mouth,  and  by  a  sudden  act  of  inspiration, 
in  laughing  or  coughing,  draw  them  into  the  larynx.  In  anesthetized 
patients,  or  those  in  a  drunken  stupor,  vomited  matters  may  be  simi- 
larly aspirated  into  the  air  passages.  Severe  paroxysms  of  choking 
ensue,  but  very  rarely  does  rapid  death  from  asphyxia  occur.  Apart 
from  asphyxia,  the  chief  danger  is  due  to  secondary  pulmonary  inflam- 


666  SURGERY  OF   THE  FACE,   MOUTH,  AND  NECK 

mation.  Occasionally  a  foreign  body  is  arrested  in  the  larynx,  but  in 
most  instances  it  passes  down  into  the  trachea,  and  thence  usually 
into  one  or  other  })ronchus. 

Symptoms. — Symptoms  depend  on  the  site  of  the  foreign  body,  and 
on  the  time  which  has  elapsed  since  the  accident.  The  first  symptoms, 
or  those  of  obstruction,  seldom  last  very  long.  They  are  succeeded 
by  those  of  irritation,  denoted  by  a  short  croup\'  cough,  with  retro- 
sternal pain,  and  later  by  mucous  or  bloody  expectoration;  paroxysms 
of  dyspnea  occur  from  time  to  time  when  the  foreign  body  is  forced 
upward  into  the  larynx.  If  impacted  in  the  larynx,  symptoms  of 
obstruction  persist,  and  there  usually  is  aphonia.  If  impacted  in  a 
bronchus,  or  if  immovably  fixed  at  any  point  b\-  a  sharp  projection 
catching  in  the  mucous  memV)rane,  the  symptoms  of  irritation  are  not 
very  marked;  and  auscultation  over  the  region  of  the  lung  obstructed 
usually  detects  very  weak  or  absent  respiratory  murmur,  but  no  dulness 
is  found  on  percussion  until  inflammatory  changes  arise.  If  the  for- 
eign body  moves  freely  about  in  respiration,  the  symptoms  of  irritation 
are  very  pronounced,  and  occasionally  the  foreign  body  can  be  heard 
flapping  about. 

Diagnosis. — The  diagnosis  in  small  children  must  be  made  from 
"  croup'"  or  diphtheria,  and  in  the  absence  of  a  clear  history,  and  where 
there  is  no  evidence  of  diphtheritic  membrane  in  the  pharynx,  this  is 
difficult,  without  laryngoscopic  examination.  When  a  foreign  body  is 
present  dyspnea  occurs  particularly  in  expiration,  while  in  laryngeal 
obstruction  from  other  causes,  inspiratory  dyspnea  is  found.  ^lore- 
over,  if  the  foreign  body  is  sufficiently  dense  ( a  pebble  or  some  metallic 
toy),  its  presence  will  be  revealed  by  the  .r-ray.  In  the  case  of  foreign 
bodies  impacted  in  the  pharynx  or  esophagus  there  rarely  is  so  much 
dyspnea,  and  swallowing  will  be  difficult  or  impossible.  A  foreign 
body  in  the  pharynx  usually  can  be  reached  b\'  a  finger  introduced 
into  the  mouth. 

Treatment. — 1 .  In  emergencies,  any  physician  may  open  the  trachea 
and  extract  the  foreign  body  if  it  can  be  found.  If  impacted  in  the 
larynx,  high  tracheotomy  or  crico-thyrotomy  should  be  preferred. 
In  other  cases  low  tracheotomy  is  better.  Even  if  the  foreign  body  is 
not  found  it  is  more  apt  to  be  discharged  spontaneously  through  a 
tracheotomy  wound  than  by  the  natural  passages. 

2.  When  there  is  no  emergency,  the  services  of  a  skilled  laryngologist 
should  be  procured.  He  may  be  able,  by  means  of  a  bronchoscope 
introduced  through  the  mouth  (upper  bronchoscopy)  to  see  and  extract 
the  foreign  body  (Fig.  707).  If  it  is  situated  too  low  to  be  reached 
successfully  from  above,  the  same  method  may  be  employed,  the 
instrument  being  introduced  through  a  "low  tracheotomy"  wound 
(p.  670),  the  procedure  then  being  known  as  lower  bronchoscopy  (Fig. 
708).  Bronchoscopy  was  introduced  by  Killian  in  1897.  and  has  been 
highly  developed  by  Guisez  in  France,  and  by  Che^•alier  Jackson  in 
this  country.  R.  T.  ^Morris  and  Huber  (1910)  have  employed  it  very 
successfully  in  conjunction  with  fluoroscopic  inspection  of  the  foreign 


Sl'RCERY  OF  TflE  MR  I'ASSAdES  007 

body  (luring  tlie  inaii<ruvms  of  extraction.  (Icncral  anesthesia  usually 
is  recjuired.  In  early  cases  upper  l)ronchoscoi)y  may  he  successtul, 
but  when  i)nlnionary  complications  exist  lower  l)ronchoscoi)y  is  to  he 
preferred. 


Fig.  707. — Upper  bronchoscopy. 


Fig.  708. — Lower  bronchoscopy. 

Fracture  of  the  Larynx  is  rare.  The  thyroid  is  the  cartilage  most 
often  involved.  :\lichel  (1910)  has  studied  40  cases  recently  reported. 
Among  these  there  were  17  deaths.  Seven  of  these  patients  died 
suddenly,  without  operation,  at  periods  varying  from  a  few  hours  to 
six  davs  after  the  accident.  The  mortality  in  non-operative  cases  is 
42  per  cent.  In  ver\-  severe  injuries,  where  the  fracture  is  compound 
internallv  (hemoptvsis,  threatening  asphyxia  from  edema  of  the  glottis) 
tracheotom>-  should  be  done,  and  the  deformity  corrected.  In  very 
mild  cases,"  no  operation  is  required,  it  being  sufficient  to  appb"  a 
light  immobilizing  dressing.  In  intermediate  cases,  especially  if  there 
is  any  emphysema,  tracheotomy  should  be  done  as  a  precautionary 


668  SURGERY  OF   THE  FACE,   MOUTH,   AND  NECK 

measure,  since  experience  shows  that  in  such  cases  sudden  death  is  apt 
to  occur  from  edema  of  the  glottis. 

Edema  of  the  Glottis. — Above  the  true  vocal  cords  there  is  abun- 
dance of  loose  areolar  submucous  tissue,  prone  to  edema  from  trauma 
or  infection.  Below  the  vocal  cords  the  mucosa  is  tightly  applied  to 
the  cartilage.  The  symptoms  of  edema  of  the  glottis  usually  develop 
very  suddenly  and  often  quite  unexpectedly.  They  are  those  of 
asphyxia.  Treatment,  which  must  be  immediate,  consists  in  crico- 
tliyrotomy  or  high  tracheotomy  (p.  670), 

Tumors  of  the  Larynx. — These  belong  rather  to  the  province  of  the 
laryngologist  than  to  that  of  the  general  surgeon,  except  when  external 
operations  are  required.  In  any  case  it  is  well  for  surgeon  and  laryn- 
gologist to  act  in  consultation. 

The  most  frequent  benign  tumor  is  the  papilloma.  It  may  occur  in 
patients  of  any  age,  but  is  most  frequent  in  young  adults.  Early 
symptoms  of  hoarseness,  with  recurrent  attacks  of  laryngitis,  finally 
will  be  followed  by  those  of  respiratory  obstruction.  The  diagnosis 
is  confirmed  by  inspection  of  the  larynx  through  a  mirror  introduced 
above  its  superior  aperture  (laryngoscopy).  Benign  growths  usually 
are  pedunculated;  ulceration  or  bleeding  points  to  mahgnancy. 
Pedunculated  growths  usually  may  be  removed  bj'  intra-laryngeal 
methods,  in  the  hands  of  a  specialist.  Papilloma  is  very  apt  to  recur, 
but  other  forms  of  benign  tumors  rarely  return.  The  performance  of 
tracheotomy,  with  the  use  of  a  tracheal  tube  sometimes  has  served 
to  prevent  recurrence,  by  putting  the  larynx  completely  at  rest. 

Carcinoma. — Carcinoma  is  the  most  frequent  malignant  tumor.  It 
is  said  to  be  rare  as  a  sequel  of  papilloma.  Sarcoma  is  very  rare. 
In  many  cases  the  growth  involves  the  larynx  secondarily,  having 
originated  in  the  tongue,  pharynx,  or  esophagus ;  this  form  is  described 
as  extrinsic  carcinovm  of  the  larynx,  as  distinguished  from  intrinsic 
carcinoma,  arising  primarily  within  the  larynx.  The  symptoms  are 
the  same  as  in  benign  growths,  but  the  patients  are  older  (it  is  rare 
before  fifty  years),  there  is  more  pain,  and  sometimes  there  is  sponta- 
neous bleeding.  The  diagnosis  is  made  by  laryngoscopy,  and  if  neces- 
sary by  microscopical  examination  of  an  excised  portion  of  the  growth. 
The  disease  usually  is  more  extensive  than  it  seems.  Tuberculosis 
and  syphilis  have  to  be  considered,  but  usually  may  be  excluded  by 
the  history  of  the  case,  by  clinical  examination,  and  by  laboratory 
tests.  The  pjrognosis  of  carcinoma  of  the  larynx  is  bad.  ^Yithout 
operation  death  usually  occurs  within  three  years,  and  it  is  a  very 
painful  death.  Treatment  should  be  radical  whenever  possible,  and  it 
is  best  accomplished  h\  external  operation. 


OPERATIONS  ON  THE  AIR  PASSAGES. 

Intubation  of  the  Larynx. — This  operation,  introduced  by  O'Dwyer 
in  18tS,5,  consists  in  the  introduction  into  the  larynx,  by  special  instru- 


OPERATIONS  ON   THE  Alii  PASSAGES 


()()9 


ments  passed  throii^^li  the  iiKtutli,  ol'  a  hollow  tiilK-  wliicli  is  allowed 
to  remain,  suspended  from  the  false  vocal  cords,  until  the  symptoms 
of  laryiij,a'al  stenosis,  for  which  the  operation  was  (h)ne,  have  sub- 
sided. It  is  employed  almost  solely  for  larynj,'eal  obstruction  resulting 
from  diphtheria.  The  arnuimentarium  comprises  a  set  of  hollow  hard 
rubber  tubes  of  various  sizes  suitable  for  any  age  up  to  twelve  years. 
The  approximate  size  is  determined  beforehand  by  means  of  a  scale. 
Each  tube  is  provided  with  a  hole  at  its  ui)per  end  through  which  a 
long  thread  is  passed;  the  thread  is  left  hanging  out  of  the  patient's 
mouth  and  enables  the  tube  to  be  quickly  withdrawn  if  necessary. 
The  tube  is  tiien  fitted  over  the  obturator,  which  is  screwed  securely 
to  the  introducer.  A  gag  is  placed  in  the  left  side  of  the  mouth,  and 
the  child  (not  anesthetized)  is 
held  upright  in  the  nurse's 
arms,  with  head  steadied  and 
slightly  extended.  The  surgeon 
then  introduces  his  left  fore- 
finger and  draws  the  tip  of  the 
epiglottis  forward.  The  intro- 
ducer is  then  passed  backward 
by  the  right  hand  and  the  tip 
of  the  tube  is  guided  into  the 
larvnx  by  the  fingers  of  the  left 
hand  (Fig.  709).  The  tube  is 
then  quickly  pushed  off  the 
obturator  by  means  of  the  slid- 
ing shaft  on  the  introducer, 
and  the  latter  with  the  obtur- 
ator still  attached  is  with- 
drawn. The  thread  fastened 
to  the  tube  is  left  hanging  out 

of  the  mouth,  until  it  is  certain  that  the  tube  will  be  well  borne. 
If  the  tube  has  been  passed  into  the  esophagus  by  mistake,  it 
should  be  withdrawn  at  once,  cleansed,  and  properly  reinserted.  If 
dyspnea  is  not  relieved  when  the  tube  is  in  the  larynx,  a  larger  tulje 
should  be  inserted.  If  the  tube  is  well  borne,  the  thread  may  be 
removed  after  a  few  hours.  When  necessary  the  tube  may  then  be 
removed  by  the  extractor,  reversing  the  steps  employed  in  its  intro- 
duction. 

The  mortality  due  to  the  operation  itself  is  very  inconsiderable, 
but  death  may  occur  in  spite  of  the  operation.  Intubation  should  be 
preferred  to  tracheotomy  in  all  cases  in  which  it  is  applicable.  When 
it  fails  to  relieve  the  obstruction,  tracheotomy  may  still  be  done, 
and  a  tube  inserted  below  the  obstruction. 

In  cutting  operations  upon  the  air  passages  the  patient  should  be 
in  the  "hanging  head  position"  (Fig.  676);  this  not  only  renders  the 
parts  more  accessible,  but  avoids  so  far  as  possible  aspiration  of  blood 
or  gastric  contents.     In  cases  where  partial  asphyxia  is  present,  no 


Fig.  709. — Intubation  of  larynx. 


670  SURGERY  OF   THE  FACE,   MOUTH,   AA'D  NECK 

anesthetic  is  reciuired;  in  others  local  anesthesia  nsiially  is  snfficient 
except  where  the  soft  parts  have  been  inva(le<I  hy  malignant  disease. 
Shortly  before  extensive  operations  (thxrotomy,  laryngectomy)  a 
hypodermic  injection  should  be  given  of  morphin  (gr.  I)  and  atropin 
(gr.  tjtt),  to  diminish  secretion  and  paralyze  inhibitory  impulses. 
Local  use  of  cocain,  even  when  a  general  anesthetic  is  employed,  is 
advisable  for  the  latter  purpose  also. 

Crico-thyrotomy,  in  which  an  incision  is  made  in  the  crico-thyroid 
membrane,  occasionally  is  done  for  acute  laryngeal  obstruction  in 
adults.  The  wind-pipe  is  here  most  accessible,  and  in  emergencies 
there  is  no  other  method  by  which  it  may  be  so  quickly  opened.  But 
there  is  some  danger  of  injuring  the  recurrent  laryngeal  nerve,  and  as 
the  larynx  itself  is  opened  it  is  not  considered  a  proper  operation  for 
diphtheritic  obstruction,  as  the  false  membrane  may  extend  below  the 
seat  of  operation.  But  in  cases  of  edema  of  the  glottis  this  objection 
does  not  apply.  Xo  anesthetic  is  required.  The  surgeon  fixes  the 
cricoid  cartilage  between  the  thumb  and  finger  of  his  left  hand,  and 
makes  a  small  transverse  incision  in  the  skin  over  the  crico-thyroid 
space.  The  sterno-hyoid  muscles  are  then  separated,  and  the  blade 
of  the  knife  is  entered  transversely  through  the  crico-thyroid  mem- 
brane. If  the  crico-thyroid  artery  is  wounded,  it  should  be  clamped 
and  tied  before  opening  the  larynx.  Occasionally  it  is  of  large  size. 
A  tracheotomy  tube  is  then  introduced,  and  the  after-treatment  con- 
ducted as  in  a  case  of  tracheotomy. 

Tracheotomy. — The  trachea  may  be  opened  either  above  (high 
tracheotomy)  or  below  the  isthmus  of  the  thyroid  gland  (loic  trache- 
otomy). Usually  two  or  three  rings  are  accessible  above,  and  as  many 
below  the  isthmus.  The  high  operation  usually  is  to  be  preferred  if 
the  indication  is  laryngeal  obstruction,  but,  as  already  mentioned,  low 
tracheotomy  is  preferable  for  the  removal  of  a  foreign  body  in  the 
bronchi.  The  higher  the  trachea  is  approached,  the  nearer  does  it 
lie  to  the  surface  of  the  neck ;  and  in  the  suprasternal  region  access  to 
it  is  obscured  by  numerous  veins,  which  are  markedly  engorged  in 
cases  of  respiratory  obstruction,  and  render  the  operation  much  more 
difficult  (Fig.  710).  Xo  anesthetic  is  required.  Partial  asphyxiation 
renders  the  patient  almost  insensible  to  pain,  and  the  first  incision  cuts 
all  the  sensory  nerves.  Most  surgeons  still  employ  a  longitudinal  skin 
incision,  but  I  believe  with  O.  Franck  a  transverse  one  is  better,  as 
it  is  less  liable  to  subsequent  infection,  gives  better  exposure  and 
leaves  an  inconspicuous  scar.  If  the  skin  is  pinched  up  in  the 
fingers,  the  anterior  jugular  veins  do  not  come  with  it,  and  there  is 
almost  no  bleeding.  The  interspace  between  the  sterno-hyoid  mus- 
cles is  identified,  and  these  as  well  as  the  underlying  sterno-thyroids 
are  separated,  exposing  the  trachea.  This  is  then  fixed  in  the  wound 
by  a  sharp  tenaculum.  Unless  this  precaution  is  taken  it  may  be 
very  difficult  to  cut  the  cartilages,  especially  in  an  adult,  as  the 
knife  is  apt  to  push  the  trachea  deeper  into  the  neck  or  to  one  side. 
Two  or  possibly  three  cartilages  are  then  divided,  in  the  long  axis 


OPERATIONS  ON  TIIK  AIR  PASSAGES 


iu 


of  the  trachea,   strictly  in   the  median  line,  and   a   tracheal   dilator 
(Fiji.  711)    is   introduced.     Or   the   trachea  may   be  opened  trans- 
versely, i)et\veen  two  rin<,'s;  it  will  gai)e,  owin*,'  to  the  hyperextension 
of  the  neck.     In  this  way  the  oi)eration  may  he  completed  with  no 
other    instrument  than   the  knife. 
The   operator    shoukl    take    care, 
esi)ecially    in    cases   of    diphtheria, 
that    the     violent     ])aroxysms    of 
coufjhing,  which  follow  oi)enino;  the 
trachea,  do  not  spatter  his  face  with 
false   niemhrane.      Any  membrane 
presentin<i  in  the  wound  should  be 
carefully   withdrawn.      A   tracheof- 
omy  tube  (Fig.  712)  is  then  inserted, 
and  fastened  in  place  }\v  tapes  tied 
behind   the    patient's    neck.     This 
tube  is  provided  with  an  inner  can- 
nula which  is  removed  frequently 
and    cleansed,  without    disturbing 
the  outer  tube.    As  k)ng  as  the  tube 
remains  in  pkace,  the  patient  should 
be  kept  in  a  moist  warm  atmos- 
phere; this  is  best  secured  by  em- 
ploying a  croup  tent,   and   by  the 
use  of  a  kettle  of  hot  water,  on  the 
surface  of  which  is  floated  a  small 
quantity  of  compound  tincture  of 
benzoin.     It  is  an  advantage  to  have 
the   outer  tracheotomy   tube   con- 
structed with  a  window  on  its  convex  surface,  so  that  w^hen  the  inner 
tube  is  withdrawn,  tests  can  be  made  from  day  to  day  of  the  possibility 
of  laryngeal  respiration.     In  emergencies,  where  a  tracheotomy  tube  is 
not  available,  one  may  be  constructed  out  of  a  soft  catheter  or  rubber 
drainage  tube.    It  rarely  is  possible  to  remove  the  tube  permanently 
before  the  third  or  fourth  dav.    In  cases  of  stenosis  from  cicatrix  or 


Fig.  710. — Sagittal  section  of  neck, 
showing  anatomical  landmarks  involved 
in  operations  on  the  larynx  and  trachea. 


Fig.  711. — Elsberg's  three-bladed 
tracheal  dilator. 


Fig.  712. — Tracheotomj-  tube. 


neoplasm  it  may  be  necessary  to  wear  a  tracheal  cannula  permanently. 
In  these  cases  a  tube  with  a  ball  valve,  permitting  inspiration  but 
preventing  expiration  through  the  tube,  may  enable  the  patient  to 
employ  his  larynx  in  speaking. 


672  SURGERY  OF   THE  FACE,   MOUTH,   AXD  NJECK 

Thyrotomy  or  Laryngo-fissure  consists  in  splitting  the  thyroid  car- 
tihige  in  the  mid-Hne,  turning  aside  the  halves,  and  exposing  the 
interior  of  the  larynx.  It  is  used  to  remove  sessile  benign  growths, 
and  as  an  ex])loratory  operation  in  cases  not  certainly  malignant. 
When  malignancy  exists  the  exploration  should  be  followed  imme- 
diately by  laryngectomy. 

Laryngectomy  may  be  partial  {Heniilaryngectoiiiy)  or  complete  {Extir- 
pation of  the  Larynx).  In  the  latter  operation  Hartley,  of  New  York, 
employs  (1908)  a  cross-bow  incision,  analogous  to  that  used  in  opera- 
tions on  the  cerebullum.  The  transverse  incision  passes  just  below 
the  level  of  the  hyoid  bone,  and  the  longitudinal  extends  far  enough 
downward  to  expose  the  isthums  of  the  thyroid  gland.  The  platysma, 
sterno-hyoid  and  omo-hyoid  muscles  are  turned  down  in  the  triangular 
flaps.  All  superficial  veins  and  both  superior  thyroid  arteries  are 
ligated,  the  latter  close  to  their  origin;  and  the  superior  laryngeal 
nerves  are  cut,  after  application  of  cocain  to  block  inhibitory  impulses. 
The  trachea  then  is  cut  away  from  the  cricoid,  is  turned  forward,  and 
is  sutured  end-on  into  the  lower  angle  of  the  incision.  Division 
of  the  thyroid  isthmus  and  free  separation  of  the  trachea  from 
the  esophagus  may  be  necessary.  A  tracheotomy  tube  is  then  intro- 
duced, and  the  anesthetic  subsequently  administered  by  this  route. 
The  sternothyroid  muscles  are  then  divided  below  the  larynx.  The 
pre-laryngeal  and  lateral  laryngeal  lymph  nodes  are  then  raised, 
together  with  the  larynx  and  attached  sterno-thyroid  muscles,  and  the 
pharynx  is  incised  transversely  behind  the  larynx,  and  the  larynx, 
including  the  epiglottis,  is  removed.  All  bleeding  having  been  con- 
trolled, the  pharynx  is  completely  closed  by  sutures  (over  a  stomach 
tube,  passed  through  the  nose,  and  used  as  a  guide)  ;^  the  musculo- 
cutaneous flaps  are  replaced  and  sutured,  and  the  wound  is  drained 
from  one  or  both  lateral  angles.  After-treatment  is  conducted  as  in 
cases  of  tracheotomy.  The  patient  should  lie  in  the  head-low  position, 
and  should  not  swallow  anything  for  three  days.  Until  then  he  may 
be  fed  liquids  through  the  tube  passed  by  the  nose  into  the  esophagus 
at  the  time  of  operation.  Crile  (1913)  points  out  that  the  chance 
of  infection  may  be  lessened  by  a  preliminary  operation  in  which  the 
suprasternal  space  is  widely  opened  on  both  sides  of  the  trachea  and  is 
packed  with  gauze.  After  several  days  when  the  wound  is  covered  with 
firm  granulations,  the  surgeon  proceeds  to  extirpation  of  the  larynx. 

The  mortality  of  the  operation  is  about  20  per  cent.  Nearly  50 
per  cent,  of  those  who  recover  remain  free  of  recurrence  for  one  year 
or  longer.  About  20  per  cent,  of  those  who  recover  are  permanently 
cured.  Recurrence  usually  takes  place,  if  at  all.  within  one  year. 
If  the  deep  cervical  lymphatics  are  involved,  no  radical  operation  is  of 
any  use. 

Hemilaryngedomy  is  done  by  turning  down  a  triangular  flap  on  one 
side  only.  A  tube  is  inserted  in  the  trachea  well  below  the  cricoid, 
and  after  preliminary  laryngo-fissure,  the  diseased  half  of  the  thyroid 
cartilage  is  removed,  with  its  related  lymph  nodes. 

^  This  tube  should  be  allowed  to  remain. 


SURGERY  OF  THE  NECK 


073 


SURGERY  OF  THE  NECK. 

Wounds.  Tlu'se  niiiy  he  incised,  lacerated,  ^niiisliot,  or  stal)  wounds. 
The  chief  inunediate  danj^'er  is  heniorrhaj^e  or  edema  of  the  ^h)ttis. 
Injuries  of  nerves,  if  undetected  and  not  repaired,  may  lead  to  lasting 
disahility.  In  suicidal  cut-thront,  the  patient  often  loses  his  courage 
when  hlood  hegins  to  flow,  and  the  damage  may  not  be  nearly  so  great 
as  appears  at  first  sight.  If  the  trachea,  larynx,  or  {)liarynx  are 
wounded,  it  frequently  is  safer  to  insert  a  tracheotomy  tube  at  once, 
to  prevent  asphyxia  should  edema  of  the  glottis  occur.  Usually  no 
anesthetic  is  necessary.  Hemorrhage  should  be  controlled  by  expos- 
ing, clami)ing,  and  ligating  the  l)leeding  i)oints.  ^'enous  bleeding  may 
cease  after  respiratory  obstruction 
has  been  relieved  by  tracheotomy. 
The  superior  laryngeal  and  the 
h\l)oglossal  nerves  are  those  most 
frecpiently  severed  in  suicidal  at- 
tem})ts.  No  prolonged  attempts 
should  be  made  to  repair  the  nerve 
injury  unless  the  patient's  condi- 
tion is  favorable.  A  lodged  bullet 
need  not  be  removed  unless  ^■ery 
easily  accessible.  Severed  muscles 
should  be  sutured.  The  wound 
should  be  drained  freely,  as  it  is 
in  a  region  very  prone  to  infec- 
tion. 

Woody  or  Ligneous  Phlegmon 
of  the  Neck  (Reclus,.  1893;.— This 
is  a  slow  and  indolent  inflamma- 
tion, j)robably  due  to  attenuated 
bacterial  infection,  the  portal  of 
entrance  of  the  infection  being  ini- 
certpin.  The  inflammatory  pro- 
cess is  said  usually  to  begin  below 
the  jaw  in  the  submaxillary  or 
submental  region,  and  extends  to 
the  clavicle,  usually  on  one  side 
only.  It  converts  the  normally 
supple  neck  into  a  dense  board- 
like structure,  neither  painful  nor 
tender,  and  not  attended  by 
noticeable  constitutional  reac- 
tion. There  may  be  an  erythematous  blush  in  the  skin,  and  pos- 
sibly some  pitting  on  very  firm  pressure,  but  there  is  no  evidence 
of  suppuration.  The  affection,  which  seems  to  be  a  cellulitis,  begins 
insidiouslv  and  ma^'  last  for  weeks  before  medical  attention  is  sought 
(Fig.  713). 
43 


Fig.  713. — Woody  or  ligneous  phlegmon 
of  neck.  Struck  by  steel  two  months  ago. 
Slow,  painless  onset  of  induration,  which 
extends  from  mandible  nearly  to  clavicle, 
and  from  larynx  to  anterior  border  of 
trapezius.  Skin  red,  slight  edema,  and 
pitting  on  pressure.  No  tenderness. 
Poulticed  for  three  daj's,  then  incised. 
Rapid  recovery.     Episcopal  Hospital. 


674 


SURGERY  OF   THE  FACE,   MOUTH,   AND  XECK 


Treatment. — The  hoard-like  area  should  he  incised  in  several  places, 
and  the  neck  should  be  poulticed.  After  suppuration  is  established, 
the  indurated  tissues  quickly  soften,  and  recovery  usually  is  unevent- 
ful. This  disease  must  not  be  confused  with  actinomycosis;  the  chief 
point  of  resemblance  is  the  board-like  induration. 

Lymphadenitis. — Inflammation  of  the  lymph  nodes  probably  occurs 
oftener  in  the  neck  than  in  any  other  portion  of  the  body.  The 
cavities  of  the  nose,  mouth,  and  pharynx  constantly  breed  hordes 
of  microbes,  and  whenever  the  virulence  of  these  is  increased,  or  the 
resistance  of  the  patient  lowered,  they  or  their  toxins  are  absorbed, 
largely  through  carious  teeth  or  the  tonsils,  and  secondary  enlarge- 
ment of  the  cervical  lymph  nodes  follows.  The  scalp  also  is  a  very 
prolific  source  of  infection  for  the  cervical  lymph  nodes.  Every  year 
I  see  a  number  of  patients  with  cervical  adenitis  due  to  the  infection 
instituted  by  head  lice. 

It  is  of  the  utmost  importance  not  to  regard  the  lymphadenitis  as 
the  main  feature  of  the  disease.  The  focus  of  infection  always  should 
be  looked  for,  and  usually  can  be  found  if  the  examination  is  thorough. 
If  it  is  found  and  properly  cared  for,  the  lymphadenitis  may  subside 
spontaneously.    Examine  the  scalp,  ear,  teeth,  lips,  tonsils,  nose,  and 

naso-pharynx,  and  do  not  be 
satisfied  until  some  source  of 
infection  has  been  discovered. 
The  anatomical  connections  of 
the  various  groups  of  cervical 
lymph  nodes  should  be  re- 
membered. Around  the  upper 
part  of  the  neck,  as  a  collar, 
are  arranged,  from  before 
backward,  the  submental,  sub- 
maxillary, subparotid,  post-auri- 
cular and  occipital  lymph  nodes, 
draining  corresponding  areas  of 
the  face  and  head.  The  sub- 
maxillary nodes  receive  the 
drainage  from  all  of  the  other 
groups  mentioned  except  the 
occipital,  and  sometimes  the 
submental ;  and  all  these  groups 
directly,  or  indirectly  through 
the  submaxilhry,  drain  into  the 
upper  portion  of  the  deep  cer- 
vical lymph  nodes,  which  form  a  chain  along  the  internal  jugular  vein 
from  mastoid  nearly  to  clavicle.  These  deep  cervical  lymph  nodes 
sometimes  are  infected  directly  from  the  primary  focus  of  the  teeth, 
tonsils,  scalp,  etc.,  without  implication  of  the  intermediary  group, 
but  in  most  cases  the  latter  is  infected  first.  The  deep  cervical 
lymph  nodes  are  also  connected  with  the  supraclavicular  lymph  nodes, 


Fig.  714. — Tuberculous  cervical  and  axillary 
adenitis,  in  a  girl  of  fifteen  5-ears;  duration 
nearly  one  year.  Has  had  two  operations  on 
neck,  both  probably  incomplete;  last,  one  year 
ago.     Episcopal  Hospital. 


Slh'<;l':iiY   OF   THE  \ECK 


G75 


which  (iraiu  the  surfaces  of  the  upper  arm  and  axilhi,  and  sumetimes 
the  <)ccij)ital  i)()rti()n  of  tlie  scalj)  and  the  inaniiuary  ^hind.  'J'hese 
sui)racla\icuhir  1\  nii)h  nodes  may  l)e  infected  tlirough  tlie  deej)  cervical 
lymph  nodes,  or  may  in  turn  infect  tliem.  The  deep  cervical  and 
supracla\icular  nodes  are  tliemselves  drained  into  the  subclavian  vein 
at  its  junction  with  tlie  internal  jufjular.  The  deej)  l\inj)h  nodes 
()f  the  neck  lie  beneath  the  sternomastoid  muscle,  and  u])on  the  fascia 
which  covers  the  prevertebral  muscles  (scaleni,  levator  anguli  scapulae, 
etc.);  their  efferent  vessels  do  not  pass  into  the  mediastinal  nodes, 
but  occasionally  they  receive  afferent  lym})hatics  from  this  source. 
Occasionally  the  axillary  lymph  nodes  become  involved  by  infections 
tra\ellin<;  down  the  neck  and  through  the  supracla\'icular  nodes 
(Fig.  714). 

Acute  Lymphadenitis. — The  affected  nodes  are  swollen,  tender,  palpa- 
ble, and  sometimes  visible  as  a  diffuse  swelling  (Fig.  715).  The  more 
acute  the  process  the  less  distinctly  can  the  individual  node  be  out- 
lined, and  in  many  cases  the  affection  is  so  acute  that  suppuration 
has  occurred  before  the  surgeon  is  consulted.  In  the  earlier  stages, 
attention  to  the  focus  of  infection, 
and  application  of  ichthyol,  bella- 
donna and  mercury,  or  compound 
iodin  ointment  to  the  side  of  the 
neck  affected  usually  cause  sub- 
sidence of  acute  symptoms,  and 
the  nodes  cease  to  be  palpable. 


Fig.  715. — Acute  submental  lymph- 
adenitis.    Children's  Hospital. 


Fig.  716. — Submaxillary  abscess  from 
acute  lymphadenitis  (not  tuberculous), 
due  to  carious  teeth.  Age  eleven  years. 
Two  months  later  other  abscesses  formed, 
were  incised  and  curetted.  One  year 
later,  formal  operation  for  tuberculous 
lymph  nodes,  evidently  secondary  to 
previous  inflammation.  (See  Fig.  36.) 
Episcopal  Hospital. 


Abscess  from  cervical  lymphadenitis  (Fig,  716)  requires  the  same 
treatment  as  an  abscess  elsewhere;  but  as  in  many  cases  the  abscess  is 
quite  deeply  seated,  it  often  is  best  to  open  it  by  Hilton's  Method;  a 
small  superficial  incision  is  made  in  the  skin,  under  local  anesthesia  if 
necessary,  and  then  a  grooved  director  is  cautiously  insinuated  through 


676 


SURGERY  OF   THE  FACE,   MOUril,   AND  NECK 


the  intervening  structures  until  pus  begins  to  flow;  a  pair  of  dressing 
forceps  is  then  passed  along  the  grooved  director,  with  its  blades 
closed;  when  it  has  entered  the  abscess  cavity  the  blades  are  opened, 
and  the  forceps  is  withdrawn,  thus  dilating  the  tract  previously  made. 
In  this  way  there  is  no  danger  of  injuring  important  bloodvessels  or 
nerves. 

Chronic  Lymphadenitis. — Chronic  lymphadenitis  usually  follows  re- 
peated acute  attacks,  the  nodes  retaining  some  inflammatory  hyper- 
plasia after  each  new  infection.  In  the  vast  majority  of  cases,  under 
these  circumstances,  the  nodes  become  secondarily  infected  with 
tubercle  bacilli.  It  is  possible,  of  course,  that  the  primary  infection 
may  have  been  tuberculous,  since  even  in  cases  which  clinically  are 
thought  not  to  be  tuberculous  microscopical  study  nearly  always 
reveals  the  characteristic  lesions  of  tuberculosis;  and  in  some  cases 
where  no  histological  indication  of  tuberculosis  was  found,  inoculation 
experiments  have  been  positive. 


Fig.  717. — Tuberculous  cervical  adenitis 
(submaxillary  and  subparotid).  Duration  six 
months.  Xo  softening  yet.  Children's 
Hospital. 


Fig.  718. — Tuberculous  cervical 
adenitis.  Age  twenty-five  years; 
duration  three  years,  no  sinus. 
From  carious  teeth.  Orthopaedic 
Hospital. 


Tuberculous  Lymphadenitis. — Tuberculous  lymphadenitis  in  the  neck 
is  an  exceedingly  common  affection.  For  anatomical  reasons,  the 
subparotid  and  submaxillary  lymph  nodes,  draining  the  tonsils,  teeth, 
and  anterior  portions  of  the  scalp,  are  those  most  often  primarily 
involved  (Fig.  717) .  Thence  the  disease  spreads  to  the  upper  deep  cer- 
vical lymph  nodes,  travels  along  those  accompanying  the  internal  jugu- 
lar vein  to  the  clavicle,  and  often  invades  the  supraclavicular  group. 
Tuberculous  cervical  adenitis  occurs  oftenest  in  those  from  fifteen  to 
twenty  years  of  age,  and  is  commoner  in  those  under  fifteen  than  in 


SlJRCEIiY   OF   Till-:   M'U'K  077 

tliosc  ]);ist  t\V(Mity-fi\('  years  ol"  aj^c.  It  may  allVct  one  or  hotli  sides  of 
the  iieek.  I'sually,  as  noted  ahoxe,  there  have  heeii  one  or  more  attacks 
of  acute  adenitis — seldom  so  acute  as  to  lead  to  sui)})uration,  and  often 
so  subacute  as  to  have  recpiired  no  medical  attention,  the  child  l)einf^ 
"doctored"  at  home  with  ham  fat  or  ^oose  fijrease.  Such  attacks  often 
date  from  the  ])eri()(l  of  con\alescence  foilowinjr  measles  or  other  acute 
exanthem.  Finally  the  nodes  become  so  conspicucms,  or  so  constantly 
tender,  even  if  invisible  to  a  casual  glance,  that  medical  attention  is 
sought.  The  nodes  are  now  more  or  less  discrete,  movable,  elastic,  but 
tender;  they  do  not  feel  hot,  and  give  no  evidence  of  fluctuation.  They 
vary  from  pea-size  to  that  of  a  walnut,  seldom  larger.  Almtjst  always 
there  are  a  great  many  more  present  than  can  be  detected  by  clinical 
examination.  When  the  affection  is  of  still  longer  duration  the  sur- 
geon finds,  instead  of  discrete,  elastic,  and  movable  nodes,  that  there 
are  ill-defined,  more  or  less  immovable  masses,  evidently  composed 
of  several  coalesced  nodes  (Fig.  718) ;  in  one  or  two  places  there  may 
be  evidence  of  softening.  At  a  still  later  stage,  cold  abscesses  form, 
spontaneous  fistulization  may  occur,  and  the  neck  is  riddled  with 
sinuses,  each  separate  and  distinct  node  as  it  softens  discharging 
through  a  new  orifice  (see  Fig.  36).  If  secondary  pyogenic  infection 
occurs,  a  hectic  state  may  develop. 

The  diagnosis  must  be  made  from  Hodgkin's  disease  and  from 
malignant  or  syphilitic  enlargements.  A  differential  diagnosis  from 
chronic  non-tuherculous  inflammation  usually  is  impossible,  at  least 
in  the  early  stages  of  tuberculosis,  except  from  the  results  of  treat- 
ment, or  by  laboratory  examination  of  an  excised  specimen.  If  cure 
of  the  infecting  focus  and  non-operative  care  of  the  neck  causes  nodes 
to  become  no  longer  palpable,  it  may  be  assumed  that  the  condition 
was  not  tuberculous,  or  only  very  slightly  so.  Hodgkins  disease 
usually  is  easily  recognized  by  the  firmness  of  the  nodes,  their  tendency 
to  enlarge  without  coalescing  or  softening,  and  by  involvement  of 
other  groups  of  lymph  nodes  as  well  as  the  cervical.  Carcinoma  is 
secondary  to  a  growth  elsewhere,  though  this  growth  may  have  been 
excised  many  years  previously,  and  there  may  be  no  local  recurrence 
and  an  inconspicuous  scar.  Such  lymph  nodes  are  hard  and  not  tender, 
and  the  patients  are  very  rarely  indeed  of  an  age  when  tuberculous 
adenitis  is  frequent.  Sarcoma  of  the  cervical  lymph  nodes  is  rare. 
In  its  early  stages  it  resembles  clinically  a  case  of  Hodgkin's  disease, 
but  affects  only  the  cervical  lymph  nodes;  it  never  suppurates,  but 
tends  to  involve  the  skin,  and  to  form  a  fungous  ulcer.  It  is  important 
to  recognize  the  existence  of  syphilis,  particularly  the  hereditary  form, 
in  cases  of  the  cervical  l\Tnpli  nodes.  It  occurs  about  puberty,  and 
its  syphilitic  nature  should  be  suspected  from  the  presence  of  other 
signs  of  the  disease  (Fig.  938). 

Prognosis  and  Treatment. — The  prognosis  of  tuberculous  cervical 
adenitis  is  bad,  unless  it  is  properly  treated.  Not  only  does  the  local 
condition  go  from  bad  to  worse,  but  the  patient's  general  health 
steadily  deteriorates.     Statistics  collected  in  1905  by  Dowd,  and  so 


678 


SURGERY  OF   THE  FACE,    MOUriL   AXD  NECK 


far  as  I  know  not  since  contradicted,  showed  that  without  operation, 
but  with  medical  treatment  only,  from  21  to  25  per  cent,  of  these 
patients  ultimately  develop  phthisis.  This  is  small  wonder,  when 
the  drainage  of  the  cervical  lymph  nodes  into  the  right  heart  is  remem- 
bered. In  1909  Dowd  traced  ninety-six  patients  on  whom  he  had 
operated  more  than  three  years  previously.  He  found  nearly  94  per 
cent,  apparently  cured;  one  death;  and  five  patients  with  recurrence 
which  could  be  cured  by  operation.  Xo  other  form  of  treatment  gives 
such  satisfactory  results.  Even  in  children,  in' whom  temporizing  and 
medical  methods  often  are  regarded  as  more  legitimate  in  this  affection 
than  in  adults,  the  prognosis  is  better  if  the  diseased  h'mph  nodes  are 
removed  by  operation.  But  in  every  case  the  source  of  injection  must 
he  cured.    Xo  matter  how  thorough  the  operation,  if  the  infecting  focus 


Fig.  719.  — ■  Tuberculous  cervical 
Ij-mph  nodes;  duration  six  months, 
following  measles.  (See  Figs.  719, 
720,  and  721.)     Children's  Hospital. 


Fig.  720. — Same  patient  as  Fig.  719, 
after  operation,  showing  temporary  para- 
lysis of  depressor  anguli  oris.  (See  also 
Figs.  721    and  722.)     Children's   Hospital. 


remains  in  scalp,  tonsil,  pharynx,  or  elsewhere,  other  nodes  not  detected 
at  the  first  operation  will  become  diseased,  and  the  patient  will  be  no 
better  off  than  before  the  first  operation.  If  there  are  chronically 
enlarged  lymph  nodes  in  the  neck,  the  first  thing,  to  do  is  to  cure  the 
source  of  infection ;  the  lymph  nodes  may  then  cease  to  give  symptoms. 
If  they  do  not,  they  almost  certainly  are  tuberculous,  and  should  be 
removed.  Occasionally  the  lymphatic  invasion  is  so  much  more 
disabling  than  the  source  from  which  the  infection  is  derived,  that  it 
is  justifiable  to  do  the  operation  on  the  cervical  lymphatics  first, 
and  to  postpone  cure  of  the  nasal  or  tonsillar  or  dental  or  scalp  con- 
dition, until  comparative  health  has  been  restored;  but  in  many  such 
cases  a  recurrence  in  the  neck  will  take  place  because  the  infecting 
focus  is  too  long  neglected.  Seldom  or  never  is  it  advisable  to  under- 
take a  nose  or  throat  operation  at  the  same  time  that  the  neck  opera- 


SL'RiJERY   OF   THE   SECK 


079 


tion  is  done.  If  there  are  adenoids,  enlarj^ed  tonsils,  etc.,  it  is  better 
to  attend  to  them  one  or  two  weeks  before  tiie  neek  operation  is  done; 
and  a  week  or  ten  days  nsually  should  ehipse  between  oj)erations  if 
both  sides  of  the  neek  are  involved.  The  neck  operation  frequently 
is  one  of  great  difficulty,  and  if  properly  done  always  is  tedious  and 
lengthy  (Figs.  719,  720,  721 ,  and  722). 


Fig.  721. 


-Same  patient  as  Fig.  719,  sliuwiiit?  Dowel's  incision  for  cervical 
adenitis.     Children's  Hospital. 


Operation. — If  the  nodes  only  in  the  upper  portion  of  the  neck  are 
involved,  they  may  be  reached  conveniently  through  Dowd's  upper 
incision,  which  runs  in  the  direction  of  the  folds  of  the  neck  an  inch  or 
more  below  the  jaw  (Fig.  721).     Cut  through  the  platysma  and  deep 


Fig.  722. — Mass  of  tuberculous  lymph  nodes  removed  entire,  showing  groove  for 
great  vessels  (three-fourths  natural  size).  (See  Figs.  719,  720,  and  721.)  Children's 
Hospital. 


fascia  before  reflecting  the  margins  of  the  wound,  so  as  to  avoid  injury 
to  the  branch  of  the  facial  nerve  which  supplies  the  depressor  labii 
inferioris;  this  nerve  runs  between  the  deep  fascia  and  platysma,  about 
a  finger's  breadth  below  the  mandible,  and  is  the  only  branch  of  the 


680 


SURGERY  OF   THE  FACE,   MOUTH.   AND  XECK 


facial  nerve  exposed  to  injury  (Fig.  720).  Then  identify  the  anterior 
border  of  the  sterno-mastoid  muscle,  and  work  under  its  margin  until 
the  carotid  sheath  is  exposed  below  the  enlarged  lymph  nodes.  These 
should  then  be  removed  by  careful  dissection  (not  blunt  tearing)  from 
below  upward,  in  one  mass  (Fig.  722).  The  chief  dangers  are  hemor- 
rhage from  large  branches  of  the  internal  jugular  vein,  especially  the 
facial  and  temporo-maxillary  veins;  and  injury  to  important  nerves, 
notably  the  hypoglossal  and  spinal  accessory. 

If  the  lower  deep  cervical  lymph  nodes  are  involved,  a  second  trans- 
verse incision,  parallel  to  the  first,  and  several  inches  lower,  may  be 
added.  These  nodes  are  most  easily  exposed  along  the  posterior  border 
of  the  sterno-mastoid  muscle.  As  one  works  along  this  from  below 
upward,  the  first  nerves  encountered  are  branches  of  the  superficial 
cervical  plexus,  emerging  about  the  middle  of  the  posterior  border  of 
the  sterno-mastoid;  and  about  an  inch  higher  up  the  spinal  accessor}' 

is  encounteredf  as  it  leaves  this 
muscle  and  crosses  the  posterior 
cervical  triangle  to  the  trapezius 
muscle.  The  sensory  nerves  may 
be  sacrificed,  but  the  spinal  acces- 
sory should  be  preserved. 

In  cases  where  there  is  very  exten- 
sive involvement,  including  the 
supraclavicular  nodes,  and  where 
the  tissues  are  densely  adherent, 
it  is  better  to  turn  down  a  large 
triangular  flap,  as  indicated  in 
Fig.  723.  This  flap  is  turned 
downward  and  forward,  the  pos- 
terior incision  being  extended  for- 
ward above  the  clavicle  if  neces- 
sary. The  dissection  is  begun  at 
the  clavicle  and  proceeds  upward, 
the  diseased  tissue  being  removed 
in  one  mass.  If  the  surgeon  can 
once  lay  bare  the  prevertebral  muscles  he  will  be  able  to  remove 
the  entire  lymphatic  area  of  the  neck.  In  exceptional  cases  trans- 
verse division  of  the  sternomastoid  muscle  may  be  necessary.  The 
existence  of  a  cold  abscess  or  even  of  a  sinus,  if  uninfected,  does  not 
interfere  with  repair  of  the  wound. 

The  wound  should  be  closed  with  two  layers  of  sutures,  the  first 
to  the  platysma  and  fascia,  and  the  second  in  the  skin.  Xeglect  to 
suture  the  platysma  separately  allows  stretching  even  of  a  transverse 
scar.  Drainage  should  be  provided  for  by  small  tube,  for  the  first 
few  days;  and  after  extensive  operations  the  patient's  head  should  be 
immobilized  by  sand-bags  until  healing  is  well  under  way. 

Tumors  of  the  Carotid  Body  or  Gland  usually  are  clinically  malig- 
nant.   Pathologically  they  are  peritheliomas  or  endotheliomas.   The 


Fig.  723. — -Flap  incision  for  cervical 
adenitis  four  months  after  operation. 
(Scars  emphasized  in  reproduction.) 
Episcopal  Hospital. 


SURGERY  OF  THE  NECK 


OSl 


timior  occurs  in  youii",^  itdiilts,  uiid  is  sl()\v-gr()\vill^^  jKiiiilcss,  dense, 
and  noii-iiiflaminatory.  Its  clinical  course  extends  throiigli  many 
years,  hut  sudden  <,To\\tli  may  dcx'elop  at  anv  time.  Eventually 
the  growth  surrounds  and  compresses  the  carotid  arteries,  and  causes 
symptoms  from  pressure,  especially  from  pressure  on  the  sympathetic, 
hypoglossal,  and  vagus  nerves.  The  dinqnosis  is  made  chiefly  by  exclu- 
sion. The  tumor  is  situated  at  the  bifurcation  of  the  common  carotid 
artery,  and  receives  transmitted  pulsation;  but  this  pulsation  is  not 
expansile,  and  there  is  no  thrill  nor  bruit.  Compression  of  the  com- 
mon carotid  artery  does  not  affect  the  tumor.  The  absence  of  primary 
growth  elsewhere,  the  long  duration,  and  the  younger  age  of  the 
patient,  exclude  carcinoma.  Sarcoma  grows  much  more  rai)idly,  and 
tends  to  soften  and  ulcerate. 

Treatment. — If  seen  very  early,  extirj^ation  may  be  undertaken; 
but  very  soon  the  operation  becomes  one  of  the  utmost  difficulty  and 
great  danger.  The  mortality  thus  far  is  about  25  per  cent.  Operation 
usually  involves  ligation  of  the  common  carotid  artery  l>elow  and  of 
the  external  and  internal  carotids  above  the  growth,  for  it  cannot  be 
separated  from  them  safely.  Other  structures  should  be  preserved  if 
possible.  In  one  case  it  was  necessary  to  remove  part  of  the  base  of 
the  skull  to  secure  the  internal  carotid  above  the  growth;  and  irre- 
parable damage  has  been  done  to  both  recurrent  and  superior  laryn- 
geal nerves,  to  the  hypoglossal  and  even  the  facial  nerve.  If  it  appear 
improbable  that  the  operation  can  be  completed,  it  should  not  be 
attempted,  or  if  begun,  should  be  abandoned  in  good  time. 


Fig.  724. — Thyro-glossal  cyst:  at 
birth  size  of  walnut;  steady  growth 
since.  Age  four  years.  Orthopaedic 
Hospital. 


Fig.  725. — Thyro-glossal  cyst;  age  four 
years.     Orthopaedic  Hospital. 


Thyro-glossal  Cysts  and  Fistulae.— The  thyro-glossal  duct  in  the 
embryo  runs  from  the  foramen  cecum  of  the  tongue  through  or  behind 
the  hyoid  bone,  in  the  mid-line  of  the  neck,  to  the  thyroid  gland.  If 
the  duct  fails  to  be  obliterated,  any  portion  which  remains  may  become 


6S2 


SURGERY  OF   THE  FACE,   MOUTH,   AND  NECK 


dilated  and  form  a  cyst;  and  if  the  cyst  ruptures  externall\-  a  fistula 
will  result.  These  cysts  and  fistulae  always  are  in  the  median  line  of 
the  neck.  They  may  be  above  the  hyoid  bone,  over  it,  below  it,  or 
the  entire  thyro-glossal  duct  may  be  persistent.  Usuallv  these  cysts 
are  noted  in  childhood  (Figs.  724  and  725),  but  sometimes  no  trace  of 
them  IS  observed  until  puberty  (Figs.  720  and  727).  The  cvst  slowly 
and  painlessly  increases  in  size,  and  relief  is  sought  for  deformitv  or 
pressure  effects.  A  thyro-glossal  fistula  secretes  a  little  mucoid  matter; 
pain  may  result  from  retention  of  its  contents  if  the  orifice  becomes 
scabbed.  Suprahyoid  cysts  are  lined  by  stratified  squamous  epithe- 
lium; those  arising  lower  in  the  thyro-glossal  tract  are  lined  bv 
columnar  (sometimes  cilated)  epithelium. 


Fig.  726. — Thj-ro-glossal  cyst,  age 
fourteen  years;  duration  one  year. 
Episcopal  Hospital. 


Fig.  727. — Thyro-glossal  cj'st.    Same  patient 
as  Fig.  726.     Episcopal  Hospital. 


Treatment. — Extirpation  should  be  done,  removing  carefully  every 
trace  of  the  duct  wall.  Recurrence  will  take  place  if  any  portion 
remains.  The  dissection  is  difficult  and  should  not  be  undertaken 
by  an  unskilled  operator. 

Branchial  Cysts  and  Fistulae.— These  result  from  maldevelopment 
of  the  branchial  arches  and  clefts  of  embryonic  life.  They  are  situated 
laterally  in  the  neck,  and  thus  are  easily  distinguished  from  the  median 
thyro-glossal  remains.  Branchial  fistulae  usually  open  along  the  anterior 
border  of  the  sterno-mastoid  muscle,  and  may  extend  as  far  as  or 
even  into  the  pharynx.  The  condition  is  congenital,  but  the  patient 
may  not  seek  relief  until  adult  life,  and  the  cysts  may  be  of  insignifi- 
cant size  until  the  occurrence  of  some  injury  (Fig.  728).  If  the  cyst 
lies  near  the  pharynx  it  will  have  lymphoid  tissue  in  its  walls. 


SURGERY  OF  THE  NECK 


()S8 


Treatment.  Extirpation,  which  is  the  only  successful  treatment, 
invoK  cs  a  verv  much  more  delicate  dissection  than  that  ot  the  median 
evsts  already"  mentioned;  and  even  skilled  dissectors  may  have  to 
repeat  the  o'peration  a  numl.er  of  times.  Disten.lmK  the  sinus  with 
parafhn.  wliich   is   injected    hot    and    allowed  to  hanlen  ni  .<^itii,  is  a 

''Branchiogenic  Carcinoma  (Langenbeck,  1861;  Volkrnann  1882) - 
Occasionallv  a  carc-iiu.ma  .levelops  in  a  branchial  cleft  Diagnosis 
before  operation  is  difhcult.  It  may  resemble  a  tumor  of  the  carotid 
bodv,  but  occurs  in  older  persons,  its  duration  is  measured  by  ^yeeks 
or  months,  not  bv  vears,  and  it  is  adherent  to  the  skin.  Treatment 
involves  extirpation  of  the  tumor  with  the  overlying  skin. 


Fig.  72S. — Branchial  cyst  of  neck;  age 
eighteen  vears;  duration  seven  months; 
followed  a  fall.     Orthopaedic  Hospital. 


YiQ  729. — Cystic  fibroma  of  cheek 
and  neck;  twenty-five  years'  duration. 
Weight  of  tumor  three  pounds  and  tive 
ounces.  Excised  by  the  late  Prof. 
Ashhurst,  1896.    University  Hospital. 


Hygroma.-This  is  an  old  clinical  term  used  to  describe  cervical 
evsts  of  diflerent  nature.    The  subject  has  been  studied  recently  by 
Dowd  (1913).     Some  are  lymphangeiomatous  m  character:  these  are 
congenital,  usually  occupy  the  posterior  triangle,  seldom  cause  dis- 
abilitv,  often  grow  smaller  and  may  even  disappear  as  the  patients 
grow  older.    Their  removal  is  difficult  and  dangerous,  and  should  not 
be  attempted  unless  pressure  symptoms  render  relief  imperative. 
Often  the  most  that  can  be  done  is  to  excise  the  anterior  and  parts 
of  the  lateral  walls  of  the  cyst,  and  pack  its  cavity  with  gauze^  looking 
for  a  cure  bv  granulation,  cicatrization,  and  contraction.    Occasion- 
allv the  cvst  extends  into  the  axilla.     Hemorrhagic  cysts  may  result 
from  traumatic  or  spontaneous  hemorrhage  into  ^  p^xisting  cyst 
Bursal   cysts,  occurring  in  preexisting  bursse  around  the  hyoid  bone 
or  thyroid  cartilage,  result  from  effusion  due  to  trauma  or  constitu- 
tional disease. 


684  SURGERY  OF   THE  FACE,   MOUTH,   AND  NECK 

Lipoma  is  freciueiit  in  the  neck.  Fibroma  is  ratlicr  unusual;  it  gen- 
erally springs  from  the  deep  fascia,  is  slow  growing;  may  in  time 
undergo  degenerative  changes  (Fig.  729),  and  reaches  an  immense  size. 

SURGERY  OF  THE  THYROID  GLAND. 

Inflammation. — Inflammation  of  the  normal  thyroid  gland  is  com- 
paratively rare.  It  is  described  as  thyroiditis,  and  must  be  distin- 
guished from  strumitis,  or  inflammation  of  a  goitrous  gland  (p.  688). 
Acute  thyroiditis,  seldom  leading  to  abscess,  occurs  by  infection 
through  the  blood-stream  in  general  infections  such  as  typhoid  fever, 
scarlatina,  etc.  The  entire  gland  is  enlarged  and  tender,  and  pressure 
symptoms  are  usual.  If  suppuration  is  suspected  an  incision  should 
be  made.  If  multiple  abscesses  exist,  or  if  necrosis  occurs,  partial 
excision  should  be  done.  Chronic  thyroiditis  is  much  less  unusual  than 
the  acute,  and  usually  is  chronic  from  the  start,  seldom  following  an 
acute  attack.  It  occurs  usually  in  alcoholic  or  arteriosclerotic  adults, 
and  may  be  caused  by  syphilis  (gummatous  form),  tuberculosis,  or 
prolonged  use  of  iodin.  Operation  may  be  required  for  diagnosis 
in  cases  of  asymmetrical  involvement  of  the  gland,  or  to  relieve  pres- 
sure. Ligneous  or  woody  thyroiditis  (Riedel,  1896)  is  believed  by  Delore 
and  Alamartine  (1911)  at  times  to  be  one  of  the  manifestations  of 
what  Poncet  calls  inflammatory  tuberculosis.  Clinically  the  diagnosis 
from  carcinoma  is  difficult,  and  pathologists  interpret  the  histological 
pictures  differently.  Compression  of  the  trachea  is  frequent,  and 
demands  intervention.  This  should  consist  merely  in  resection  of  the 
thyroid  isthmus.  Radical  operation  is  nearly  impossible  and  is  not 
necessary.    The  use  of  the  .r-ray  may  hasten  regression  of  the  disease. 

Goitre. — This  is  a  clinical  term  used  to  describe  an  enlargement 
of  the  thyroid  gland.  It  is  derived  from  the  Latin  word  for  throat 
(guttur).  The  thyroid  is  an  epithelial  gland  which  in  embryonic  life 
had  a  duct,  the  thyroglossal  duct.  The  presence  or  absence  of  a  goitre, 
and  the  existence  or  non-existence  of  constitutional  symptoms  in  con- 
nection with  it,  depend  on  the  inter-relation  of  secretion  and  absorp- 
tion in  the  thyroid  gland.  In  fetal  life  there  is  little  or  no  evidence  of 
secretion.  At  puberty  the  thyroid  becomes  more  active,  and,  as  noted 
below,  sometimes  enlarges.  In  adult  life  whatever  secretion  is  pro- 
duced is  normally  absorbed  by  the  body  tissues.  In  abnormal  states 
there  is  excess  of  secretion,  and  this  is  either  not  so  absorbed,  and 
accumulates  in  the  thyroid  ("cystic"  goitre);  or  else  is  absorbed  and 
produces  toxemia  (hyperthyroidism).  Whenever  hyperthyroidism 
exists  there  is  an  increase  in  the  secreting  surface  of  the  thyroid; 
this  results  either  in  a  parenchymatous  hypertrophy  (without  cyst 
formation),  or  in  intra  cystic  papillomatous  out-gro^i:hs  (if  the  change 
occurs  in  a  thyroid  previously  cystic).  When  instead  of  paren- 
chymatous hypertrophy,  there  is  marked  increase  in  the  interglandular 
connective  tissue,  the  amount  of  secreting  surface  is  relatively 
decreased;  this  is  the  case  in  the  thyroids  of  cretins  (hypothyroidism) 


SURGERY  OF  THE   THYROID  GLAND 


()S5 


and  tlic  ttTin  hyptTtropliic  fetal  thyroid  is  ai^jjlicd.  11'  in  a  fetal  type 
of  thyroid  the  epithelial  (secreting)  elements  are  in  excess,  we  have 
an  adenomatous  thyroid,  and  symi)t()ms  of  hyperthyroidism  ma\'  or 
may  not  he  present.  Patients  in  whom  atrophy  of  secreting  cells  has 
occurred,  usually  as  the  result  of  pressure  from  accumulated  and  not 
absorbed  secretion  (chiefly,  therefore,  in  cases  of  cystic  thyroid),  are 
those  who  are  spontaneously  cured  of  their  toxic  symptoms;  in  some 
such  cases  the  final  state  may  be  one  of  hypothyroidism  (jMacC"art\', 
1910). 

Physiological  enlargement  of  the  thyroid  gland  often  occurs  in  girls 
at  puberty  (Fig.  730),,  the  enlargement  persisting  for  a  year  or  more 
and  then  gradually  subsiding. 
Sometimes  enlargement  recurs  at 
every  menstrual  period  or  during 
pregnancy;  and  occasionally  the 
enlargement  which  appeared  at 
puberty  never  subsides.  The 
gland  is  uniformly  and  symmetric- 
ally enlarged.  No  symptoms  are 
present  and  the  patient  may  not 
be  aware  of  the  existence  of  a  goitre. 
Xo  treatment  is  required. 

Pathological  enlargement  of  the 
thyroid  gland  is  endemic  in  certain 
regions,  notably  in  Switzerland;  it 
is  frequent  in  French  Canada,  and 
in  some  other  parts  of  North 
America.  It  is  generally  believed 
that  this  enlargement  is  associated 
in  some  way  with  the  drinking 
water  of  the  patients;  and  it  seems 
probable  that  the  cause  is  some 
qualitative  change  in  the  iodin 
constituents  of  the  drinking  water. 

The  enlargement  may  be  diffuse  or  circumscribed  ("jiodular").  This 
classification  of  Kocher  is  in  general  use,  and  is  very  convenient  for 
purposes  of  clinical  study. 

Diffuse  enlargement  involves  both  lateral  lobes  and  isthmus  pro- 
portionately. It  usually  is  due  to  more  or  less  uniform  increase  in 
all  the  elements  of  the  thyroid  {follicular  and  parenchymatous  goitre) 
or  to  disproportionate  increase  in  the  colloid  material  {colloid  goitre). 
In  the  latter  and  more  frequent  form,  the  consistency  of  the  swelling 
is  harder,  and  the  individual  lobules  appear  larger  and  are  more 
easily  defined.  A  diffuse  rascular  goitre  is  one  of  any  form  in  which 
vascularity  is  marked.  A  diffuse  fibrous  goitre  is  the  result  of  inflam- 
mation and  cicatricial  changes  in  any  of  the  forms  mentioned,  and  is 
very  rare.  There  is  also  a  form  of  diffuse  adenomatous  goitre  which 
it  is  better  to  classify  among  malignant  growths. 


_  Fig.  730. — Pli\-.-ioli.Lri(;al  goitre,  in  a 
girl  of  thirteen  j-ears.  Orthopaedic 
Hospital. 


686 


SURGERY  OF   THE  FACE,   MOUTH,  AND  NECK 


Circumscribed  or  nodular  enlargement  may  occur  in  any  of  the  prin- 
cipal forms  already  mentioned:  follicular,  colloid,  or  adenomatous. 
The  colloid  or  "  cystic"  goitre  is  by  far  the  most  frequent  form.  Nodu- 
lar goitre  is  characterized  (1)  by  the  irregularity  and  inequality  of 
the  enlargements;  and  (2)  by  their  tendency  to  undergo  degenerative 
changes,  such  as  colloid,  hyaline,  calcareous,  etc.,  and  to  intracystic 
hemorrhages.  Single  nodules  are  most  common  in  one  of  the  lower 
poles  of  the  lateral  lobes;  occasionally  they  occur  in  one  of  the  upper 
poles;  and  very  rarely  in  the  isthmus  or  in  the  pyriform  lobe  when 
the  latter  is  present.  Multiple  nodules  may  exist.  As  the  nodules 
increase  in  size  they  displace  the  remaining  normal  gland  structure, 
and  may  become  more  or  less  encapsulated.  Occasionally  a  diffuse 
colloid  goitre  is  converted  into  a  goitre  with  multiple  cystic  nodules; 
these  have  little  tendency  toward  degeneration  or  internal  hemor- 
rhages. 

Symptoms  and  Diagnosis. —  Diffuse  goitre  retains  the  shape  of  the 
normal  gland,  and  rarely  attains  very  large  size.  The  tumor,  as  in 
all  thyroid  affections,  rises  with  the  larynx  in  the  act  of  swallowing  and 
in  coughing.  It  is  movable  laterally,  but  scarcely  at  all  up  and  down. 
Pressure  symptoms  are  rare.  Sometimes  venous  engorgement  is  visible 
over  the  root  of  the  neck  or  upper  thorax.  In  nodular  goitre  the  relation 
of  the  swelling  to  the  thyroid  is  determined  by  its  location  in  the  neck 

over  the  normal  site  of  the  thyroid, 
and  by  its  movement  with  the  larynx 
in  deep  breathing,  sw^allowing,  and 
coughing.  The  swelling  is  close  to 
the  median  line  of  the  neck,  but 
usually  is  distinctl,y  lateral  in  its  at- 
tachment. As  it  increases  in  size  it 
may  become  pendulous  (Fig.  731).  It 
pushes  forward  the  sub-hyoid  muscles, 
and  displaces  the  sterno  -  mastoid 
muscle  and  great  ^'essels  of  the  neck 
laterally,  so  that  the  vessels  may  be 
palpable  at  the  posterior  border  of 
this  muscle;  it  may  distort  or  com- 
press the  trachea  and  esophagus;  and 
may  cause  symptoms  from  pressure 
on  the  sympathetic,  recurrent,  or 
superior  laryngeal  nerves.  Rarely  a 
goitre  may  grow  down  behind  the  ster- 
num, when  its  presence  may  be  detected  by  percussion.  Finally,  a  goitre 
may  produce  disturbance  of  the  heart  and  circulation,  either  directly 
by  pressure  on  the  great  vessels,  or  through  interference  with  respira- 
tion; or  in  some  instances  from  hyperthyroidism  (p.  688).  Intermit- 
tent pressure  on  the  great  vessels  of  the  neck  may  produce  giddiness 
and  other  evidences  of  disturbances  in  the  intracranial  circulation. 
In  diffuse  follicular  and  in  imrenchymatous  goitres  the  diagnosis 


Fig.  731. — Cystic  goitre,  of  sixteen 
years'  duration  in  a  patient  of  thirty- 
seven  years.     Pennsylvania  Hospital. 


SURGERY  OF  THE  THYROU)  dLANI)  ()S7 

rests  on  the  soft,  flabby  consistency,  palpation  of  the  small  but  rather 
distinct  lobules,  and  the  vascularity.  Early  symptoms  of  hyper- 
thyroidism may  be  i)resent,  and  these  usually  will  be  increased  by  the 
administration  of  iodin.  The  (liffu,sc  roUoUl  goitre  is  relatively  firm, 
the  lobules  are  much  larger,  and  some  are  quite  hard;  iodin  causes  no 
diminution  in  size.  The  dif  use  fibrous  goitre  is  harder,  and  there  are 
symptoms  of  hypothyroidism. 

In  nodular  colloid  goitre  (cystic  goitre)  the  diagnosis  often  is  made  at 
a  glance.  The  surface  of  the  cyst  is  smooth,  its  form  is  oval  or  rounded, 
and  its  consistency  elastic.  The  adenomatous  goitre  is  recognized  by 
its  circumscribed  character,  and  its  soft  and  doughy  feel. 

Treatment.— In  many  cases  of  difi"use  goitre,  judicious  medical  treat- 
ment, with  attention  to  hygiene,  will  cause  diminution  or  complete 
subsidence  of  the  swelling.  Operation  is  required  only  for  cosmetic 
efl'ect,  to  relieve  pressure  symptoms,  or  to  check  progressive  growth 
or  a  tendency  toward  hyperthyroidism.  In  most  cases  of  nodular 
goitre  operation  is  indicated  at  an  early  stage,  for  the  same  reasons 
which  render  its  adoption  advisable  at  a  later  stage  in  the  diffuse  form. 
This  is  particularly  true  of  nodules  undergoing  degenerative  changes, 
and  especially  of  the  nodular  adenomatous  form,  since  in  this  the  ten- 
dency to  malignant  change  is  well  marked.  Finally,  it  may  be  stated 
in  general  terms,  that  any  goitre  of  rapid  growth  or  tender  on  pressure 
should  be  referred  to  the  surgeon. 

The  operation  consists  in  excision  of  the  affected  lobe;  or  in  case  of 
one  or  two  large  nodules,  in  their  enucleation;  as  the  nodules  usually 
are  fairly  well  encapsulated  the  remainder  of  the  gland  may  be  left 
intact,   to   prevent   development   of   symptoms   of   hypothyroidism. 
Enucleation  is  indicated  especially  where  it  is  probable  that  very 
little  healthy  functionating  gland  tissue  remains.     In  diffuse  goitre 
it  usually  is  found  sufficient  to  excise  one  lobe,  with  a  part  of  the  isth- 
mus; the  remaining  lobe  may  then  cease  to  cause  symptoms.    Should 
these  continue,  a  part  or  whole  of  the  second  lobe  may  be  removed 
subsequently.      Kocher's   incision  is   a  transverse   incision,   slightly 
convex  downward,  crossing  the  neck  over  the  prominence  of  the 
thyroid,  from  one  sterno-mastoid  muscle  to  the  other.    In  operations 
on  one  lobe  only,  the  incision  need  be  only  half  as  long.    The  flaps, 
including  plat^'sma  and  fascia,  are  then  dissected  upward  and  down- 
ward, exposing  the  pre-thyroid  muscles.    These  may  be  divided  near 
the  hyoid  bone,  if  necessar>',  thus  preserving  their  nerve  supply,  and 
the  tumor  may  then  be  dislocated  into  the  wound.     In  all  thyroid- 
ectomies, partial   or  complete,  hemorrhage  should   be  scrupulously 
avoided,  by  clamping   and   ligating  veins  as  they  are  encountered, 
and  securing  the  superior  and  inferior  thyroid  arteries  of  the  affected 
lobe  before  its  excision  is  begun.     Both  arteries  should  be  secured 
close  to,  or  after  entry  of  their  branches  into  the  gland.    This  is 
especially  important  in  case  of  the  inferior  thyroid,  so  as  to  avoid 
interference  with  the  circulation  of  the  inferior  parathyroid  glandule 
(p.  691).    Then  the  capsule  of  the  gland  is  split  open  along  its  lateral 


688  SURGERY  OF   THE  FACE,   MOUTH,   AND  NECK 

aspect,  and  the  lobe  is  removed,  leaving  part  of  it  adherent  to  the 
posterior  portion  of  the  capsule,  so  as  to  avoid  injury  to  the  parathy- 
roid glandules  and  the  recurrent  laryngeal  nerve.  The  occasional 
presence  of  a  thyroidea  ima  artery  should  be  remembered.  The 
isthmus  is  clamped  and  is  ligated,  in  the  groove  made  by  the  clamp, 
before  it  is  divided.  Severed  muscles  are  then  sutured,  and  the  wound 
is  closed  with  ample  drainage. 

Strumitis. — Inflammation  of  a  goitrous  thyroid  is  less  unusual  .than 
that  of  the  normal  gland.  The  diagnosis  rarely  is  flifficult,  and  the 
treatment  is  the  same  as  for  corresponding  forms  of  thyroiditis. 

Hypothyroidism. — In  persons  from  whom  the  entire  thyroid  gland 
is  removed  there  usually  develops  a  condition  of  acquired  cretinism, 
known  as  myxedema,  or  cachexia  thyreopriva.  The  signs  of  this  con- 
dition need  not  be  detailed  here.  A  knowledge  of  the  condition 
is  sufficient  to  warn  the  operator  not  to  remove  all  the  function- 
ating thyroid  tissue.  If  this  course  has  to  be  pursued  in  the  eradi- 
cation of  malignant  disease,  the  patient  should  ingest  daily  a  sufficient 
quantity  of  thyroid  extract  to  keep  the  myxedematous  symptoms  in 
abeyance.  Transplantation  of  thyroid  tissue,  from  man  and  from  some 
lower  animals,  has  been  tried  in  such  cases,  and  in  some  instances 
with  encouraging  results.  The  portions  of  thyroid  gland  have  been 
implanted  subcutaneously,  in  the  subserous  tissues,  in  the  splenic 
pulp,  and  in  the  bone  marrow.  In  most  cases,  even  if  the  graft 
functionates  properly  for  a  time,  it  eventually  is  absorbed,  and 
myxedematous  symptoms  again  develop. 

Hyperthyroidism  {Exophthalmic  Goitre,  Graves's  Disease  (1835), 
Basedow's  Disease  (1840),  Thyrotoxicosis). — Administration  of  thyroid 
extract  in  excess  to  normal  persons  causes  the  development  of  certain 
symptoms  which  are  also  present  in  some  diseased  states  of  the  thyroid 
gland.  These  symptoms  are  the  direct  antithesis  of  those  observed 
in  myxedema.  They  may  be  grouped  in  four  main  categories:  (1) 
Local  changes  in  the  thyroid.  (2)  General  circulatory  symptoms.  (3) 
Nervous  symptoms.  (4)  Metabolic  changes.  There  should  also  be 
mentioned  exophthalmos,  which  usually  is  present,  but  sometimes  is 
not  associated  with  other  typical  symptoms. 

The  affection  is  much  commoner  in  women  than  in  men  (about 
6  to  1),  and  occurs  usually  between  the  ages  of  fifteen  years  and  thirty- 
five  years;  it  is  less  rare  after  thirty-five  years  than  before  puberty. 
It  appears  to  be  induced  by  physical  or  mental  exhaustion,  worry, 
anxiety,  fright,  fear,  etc.  Sometimes  it  develops  very  acutely;  in 
others  very  rapidly,  but  not  suddenly;  at  other  times  its  onset  is 
insidious.  In  the  cases  which  develop  rapidly,  the  goitre  usually 
makes  its  first  appearance  at  the  time  that  the  thyrotoxic  symptoms 
develop;  in  the  chronic  cases,  with  slow  onset,  a  goitre  usually  has 
been  present  for  months  or  years  before  hyperthyroidism  ensues. 

Local  Changes. — The  thyroid  usually  is  enlarged  symmetrically 
and  diffusely.  Its  vascularity  is  increased,  giving  it  a  soft  feel;  but 
deep  pressure  detects  a  gland  firmer  than  normal.     Nodular  goitre 


SURGERY  OF  THR  THYUOUJ  dLAND 


()89 


rarely  is  associated  with  tli\  ro-toxie  s\  iiiptoins.  The  more  acute 
the  onset,  the  more  marked  are  the  local  ehanj^es.  In  cases  of  long 
duration,  especially  when  medical  treatment  has  heen  prolonged, 
the  gland  hecomcs  smaller  and  firmer,  hut  tiie  vascular  phenomena 
may  be  demonstrated  again  after  excitement.  In  some  cases  no  local 
changes  are  ])ercej)til)le,  and  the  diagnosis  depends  on  other  signs. 

Circulatory  Symptoms. — Tachycardia  is  the  most  prominent  symp- 
tom: the  ])ulse  is  ahnormally  frecjucnt,  (piick,  usually  of  high  tension, 
and  extremely  irritable  (A.  K'ocherj.  These  changes  may  he  acute 
in  onset,  or  very  gradually  de\elop.  Excitement  always  accentuates 
them. 

Nervous  Symptoms. — Restlessness  of  mind  and  body  is  exceedingly 
characteristic.  The  patient  inclines  to  be  hysterical,  and  weeps  with- 
out j)r()\ocation;  there  is  insomnia;  tremor,  especially  marked  in  the 
hands,  tongue,  and  lips;  and  various  psychoses  may  develop. 


Fig.   732. — -Exophthalmic    goitre.  Fig.   733.  —  Exophthalmic   goitre.    Same 

Duration  seven  year-s;  twenty-eight  patient  as  Fig.  732.     Episcopal  Hospital, 

years  old.  Has  had  seven  children. 
Goitre  has  grown  rapidly  during  the 
last  year.  No  tachycardia  or  ner- 
vousness. Exophthalmos  not  noticed 
by  patient.    Episcopal  Hospital. 

Metabolism. — In  general  terms,  all  metabolic  activity  is  increased. 
The  skin  is  warm  and  moist;  the  temperature  slightly  raised;  the 
amount  of  urine  increased;  weight  is  lost,  and  in  advanced  stages 
emaciation  may  occur.  Brown  atrophy  of  the  heart  and  degenerations 
of  the  other  viscera  develop  eventually,  and  render  recovery  impossible. 
There  is  great  weariness  quite  early  in  the  disease.  Frequent  attacks 
of  diarrhea  may  occur.  Capillary  hemorrhages  are  not  infrequent. 
The  blood-changes  are  said  by  Kocher  to  be  characteristic,  and  almost 
pathognomonic:  there  is  slight  leukopenia,  but  marked  increase  in 
the  actual  and  proportional  number  of  lymphocytes,  \vhich  may  out- 
number the  neutrophile  leukocytes;  the  red  blood  cells  and  hemoglobin 
remain  unaltered. 
44 


690  SURGERY  OF   THE  FACE,   MOUTH,  AND  NECK 

Exophthalmos  is  not  a  necessary  feature  of  hyperthyroidism.  It 
may  be  present,  and  associated  with  a  goitre,  without  any  of  the  cir- 
culatory, nervous,  or  metaboHc  symptoms  which  are  characteristic 
of  the  disease  (Fig.  732).  Its  pathogenesis  is  not  understood.  It  may 
be  absent  when  other  symptoms  of  the  disease  are  very  pronounced. 

Diagnosis. — This  depends  on  recognizing  the  circulatory,  nervous, 
and  metabolic  symptoms  which  have  been  detailed  above;  and  on  the 
blood-changes,  on  which  great  stress  is  laid  by  Kocher.  The  existence 
of  a  palpable  goitre  and  exophthalmos  are  confirmatory  signs,  but  by 
no  means  necessary  for  a  diagnosis.  The  histological  diagnosis,  as 
pointed  out  at  p.  684,  depends  on  the  recognition  of  increase  in  the 
secreting  surface  of  the  gland,  quite  apart  from  other  changes  which 
may  be  present. 

Prognosis. — Theoretically,  hyperthyroidism  is  a  self-limited  disease; 
but  the  disease  may  kill  the  patient  before  it  burns  itself  out.  In 
rare  cases  the  thyrotoxic  symptoms  subside,  perhaps  aided  by  medical 
treatment,  and  those  of  hypothyroidism  succeed.  The  thyroid  thus 
may  destroy  itself  by  hypersecretion.  But  in  most  cases  the  disease 
grows  progressively  worse.  The  more  acute  its  onset,  the  more  rapid 
is  its  course.  Acute  exacerbations  characterize  some  rather  subacute 
cases.  In  these  and  in  the  hyperacute  cases,  death  may  occur  in  a 
paroxysm,  with  rapid  cardiac  exhaustion  (delirium  cordis),  general 
edema,  albuminuria,  fever,  dyspnea,  etc.  In  other,  more  chronic,^ 
cases,  death  occurs  from  intercurrent  maladies,  such  as  influenza  or 
tonsillitis;  it  may  occur  merely  from  administration  of  an  anesthetic 
for  operative  purposes,  since  viscera  damaged  by  the  long  continuance 
of  intoxication  cannot  functionate  under  these  additional  demands. 

Treatment. — As  the  disease  is  due  to  intoxication  from  the  thyroid 
gland,  there  are  two  logical  remedies:  one  is  removal  of  part  of  the 
gland,  the  other  is  the  preparation  and  administration  of  an  antitoxic 
serum.  The  latter  has  been  tried  by  Beebe  and  Rogers,  but  not  with 
the  uniform  success  w^hich  has  attended  operative  treatment,  and 
must  be  continued  indefinitely  as  the  cause  of  the  symptoms  is  not 
removed.  In  the  hyperacute  cases  usually  no  treatment  is  of  use, 
and  death  occurs  in  a  short  time.  In  the  subacute  cases,  in  which  the 
thyrotoxic  symptoms  and  the  goitre  appear  simultaneously,  medical 
treatment  should  be  tried  before  resort  to  operation,  as  by  procuring 
absolute  rest  for  mind  and  body  it  is  possible  to  ameliorate  the  patient's 
condition.  In  most  cases  confinement  to  bed  is  imperative,  in  isola- 
tion. Local  cold  is  of  great  value  in  quieting  the  tachycardia.  Kocher 
thinks  iodin  internally  is  of  much  value.  The  bowels  and  kidneys 
must  be  looked  to,  and  a  milk  diet  may  be  beneficial.  Belladonna  or 
atropin,  with  an  occasional  course  of  bromides,  are  useful  in  controlling 
circulatory  disturbances.  If  no  improvement  is  evident  within  a 
couple  of  weeks,  it  is  useless  to  pursue  this  treatment  further,  and 
operation  should  be  undertaken,  as  it  should  even  earlier  if  the  patient 
continues  to  grow  worse,  and  in  the  more  chronic  cases  where  it  may 
be  employed  safely  without  such  careful  preparative  treatment. 


SURGERY  OF  THE  THYROID  GLAND  (391 

The  Parailit/rolds. — In  all  ()i)tTati()ns  injury  i)f  the  jjarathyroids 
should  be  avoided;  for  thou<;;h  Shepherd  attaches  little  importance 
to  them,  other  surgeons  of  etpial  or  fjreater  experience  (Kocher,  ('. 
H.  Mayo,  Crile,  Halsted)  entertain  the  greatest  respect  for  their 
powers  of  good  and  evil.  These  little  glands,  of  uncertain  function, 
usually  are  four  or  more  in  iuunl)er;  they  are  situated  two  on  each 
side  of  the  neck  behind  the  thyroid  gland,  and  separated  from  it  by 
the  posterior  ])ortion  of  its  capsule.  The  lower  pair  are  in  relation 
with  the  terminal  branches  of  the  inferior  thyroid  artery,  and  are 
the  more  constant  in  position.  The  upj)er  parathyroids  are  supplied 
either  from  the  superior  thyroid  artery  or  from  communicating 
branches  from  the  inferior  thyroid.  Removal  or  destruction  of  all 
the  parathyroids  is  supposed  to  be  the  cause  of  post-operative  tetany, 
which  has  been  seen  in  a  few  cases.  As  it  is  impossible  to  identify 
the  parathyroids  except  by  histological  examination  (macroscopically 
they  cannot  be  distinguished  from  lymph  nodes),  the  only  safe  course 
is  to  keep  clear  of  the  site  where  they  normally  are  found.  This  is 
best  done  in  excisions  by  leaving  the  posterior  portion  of  the  capsule 
and,  if  necessary,  a  layer  of  thyroid  tissue  adherent  to  it. 

Operation. — In  severe  cases  it  is  the  custom  first  to  diminish  the 
thyrotoxic  symptoms  by  ligating  one  or  more  of  the  arteries  supplying 
the  gland;  and  to  proceed  to  partial  excision  within  a  week  or  ten  days, 
before  the  favorable  effect  of  the  preliminary  operation  has  passed 
away.  In  very  acute  cases  the  patient  will  be  so  much  worried  and 
excited  by  the  anticipation  of  any  operation,  that  Crile  has  adopted 
the  ingenious  plan  of  instituting  a  course  of  very  strict  pre-operative 
treatment,  repeated  every  morning,  and  embodying  the  essential 
steps  in  preparation  for  operation,  as  if  they  in  themselves  consti- 
tuted the  treatment.  Every  morning  the  patient's  neck  is  washed  as 
if  for  operation,  and  dressings  are  applied;  every  morning  she  inhales 
some  essential  oil,  to  simulate  an  anesthetic.  Then  some  favorable 
morning,  in  the  course  of  usual  routine,  a  real  anesthetic  is  given, 
and  the  operation  is  completed  without  the  patient  being  aware  of  any 
change  from  the  daily  routine.  In  Kocher's  hands,  the  mortality  of 
operation  in  200  severe  cases  was  4.5  per  cent.;  and  there  were  S5 
per  cent,  of  cures.  In  cases  with  advanced  visceral  degenerations 
operation  is  useless. 

Ligation. — j\Iost  surgeons  follow  Kocher  in  ligating  one  or  both 
superior  thyroid  arteries.  But  Delore  and  Alamartine  (1911)  have 
pointed  out  that  the  circulation  is  much  better  controlled  if  the 
superior  and  inferior  thyroids  on  the  same  side  are  ligated.  Halsted 
(1913)  now  ligates  both  inferior  thyroids.  The  sujjerior  thyroid  artery 
is  exposed  by  a  small  transverse  incision  over  the  upper  pole  of  the 
lateral  lobe,  which  usually  is  palpable  through  the  skin;  the  sterno- 
mastoid  is  drawn  backward  and  the  omo-hyoid  forward,  and  the 
pole  of  the  gland  itself  is  ligated  extracapsularly,  in  two  places.  This 
"polar  ligation,"  introduced  in  1909  by  Jacobson  and  Stamm,  and 
adopted  by  C.  H.  Mayo,  is  valuable  as  it  does  not  interfere  with  the 


692  SURGERY  OF   THE  FACE,   MOUTH,   AND  NECK 

blood-supply  to  the  superior  parathyroids,  which  would  be  jeopar- 
dized if  the  main  trunk  was  ligated;  and  because  it  controls  the  veins 
and  lymphatics  and  also  destroys  most  of  the  vasodilator  nerves 
entering  the  lateral  lobe.  This  polar  ligation  thus  becomes  what 
Delore  and  Alamartine  call  an  angeio-neurectomy.  The  inferior 
thyroid  artery  is  best  ligated  at  its  origin  from  the  thyroid  axis,  since  it 
divides  into  numerous  branches  before  entering  the  gland,  and  separate 
ligation  of  these  is  difficult  and  exposes  the  recurrent  laryngeal  nerve 
and  inferior  parathyroid  to  injury.  The  artery  is  exposed  by  an 
incision  parallel  to  the  clavicle  at  the  posterior  border  of  the  sterno- 
mastoid;  the  anterior  scalene  muscle  is  located,  and  the  thyroid  axis 
found  just  to  its  median  border. 

Thyroidectomy. — As  in  the  case  of  simple  goitre  (p.  687)  only  one 
lateral  lobe  is  to  be  removed.  If  symptoms  persist,  half  of  the  remain- 
ing lobe  may  be  removed  at  a  second  operation.  Great  care  in  hemo- 
stasis  must  be  exercised,  and  the  wound  must  be  freely  drained. 

Sympathectomy  (Jaboulay,  1896). — Excision  of  both  superior  ganglia 
of  the  cervical  sympathetic,  effective  in  overcoming  the  exophthalmos, 
has  been  abandoned  by  most  surgeons,  because  it  has  very  little  influ- 
ence on  the  other  symptoms. 

Malignant  Tumors  of  the  thyroid  are  not  very  rare,  especially  in 
goitrous  regions.  Carcinoma  is  commoner  than  sarcoma;  endothe- 
lioma also  occurs.  Clinically,  the  distinction  is  not  of  much  impor- 
tance, since,  as  A.  Kocher  says,  "By  the  time  malignant  goitre  reveals 
its  two  chief  characteristics  it  is  too  late  for  a  radical  cure."  He 
adds  that  if  the  thyroid  continues  to  enlarge  after  puberty,  in  spite 
of  appropriate  internal  treatment,  and  in  the  case  of  any  thyroid  which 
begins  to  grow  without  any  apparent  cause  after  the  thirty-fifth  year 
of  life,  malignant  change  should  be  suspected.  The  two  chief  char- 
acteristics of  these  malignant  tumors  are  irregular  growth,  and  change 
in  consistency.  Instead  of  the  nodules  being  more  or  less  uniform  in 
distribution  and  size,  a  few  of  them  will  begin  to  project  to  an  abnormal 
degree  beyond  the  others,  and  they  will  lose  their  elastic  consistency 
and  become  firmer  and  more  flesh-like.  Pressure  symptoms  occur 
earlier  than  in  benign  enlargement,  because  of  development  of  adhe- 
sions to  surrounding  structures.  Spontaneous  pain  is  not  an  early 
symptom,  but  occurs  in  malignant  growths  much  sooner  than  in 
benign. 

Prognosis. — The  prognosis  is  bad.  Metastasis  occurs  early,  and 
may  be  the  first  evidence  of  malignancy.  In  carcinoma,  and  even 
in  histologically  benign  diffuse  adenoma,  metastasis  to  bones  is 
frequent;  and  Shepherd  has  observed  pulmonary  invasion  by  carci- 
noma through  the  internal  jugular  veins. 

Treatment. — Very  early  extirpation  is  the  only  method  that  offers 
any  hope  of  cure.  Shepherd  says  he  has  completely  excised  over  a 
dozen  thyroids,  and  never  save  in  one  case  (repeated  operations  for 
recurrence)  has  seen  any  evil  effects  attributable  to  injury  of  the  para- 
thyroids though  he  has  taken  no  care  to  preser^•e  them.     But  the 


SURGERY  OF  THE  ESOI'IIAGUS  003 

j)r()j)hylactic  julniinistratiou  ot*  j)arathyr()i(lin  is  rccommeiult'd,  aiul 
tho  use  of  thyroid  extract  may  he  necessary  to  prevent  myxedema. 
Trac'heotomy  may  he  necessary  in  tar  nd\ancc(l  in()i)eral)le  cases; 
it  may  prove  a  difficult  operation. 


SURGERY  OF  THE  THYMUS  GLAND. 

In  some  infants  acute  or  chronic  dyspnea  is  due  to  enlargement 
of  tlie  tliymus  ghmd,  which  compresses  the  trachea.  I'sually  the 
enhirged  gkmd  may  be  detected  by  percussion,  and  its  presence 
should  be  suspected  when  tracheotomy  fails  to  relieve  the  dyspnea. 
Then  the  incision  may  be  extended  down  to  the  episternal  notch, 
when  the  thymus  (much  like  an  enlarged  lymph  node)  will  protrude 
from  the  anterior  mediastinum,  and  may  be  drawn  up  into  the  neck. 
In  some  cases  it  has  been  sutured  to  the  sterno-mastoid  muscle  to  keep 
it  from  again  becoming  wedged  in  the  thoracic  opening,  but  it  is  better 
to  enucleate  it  from  its  capsule  and  remove  as  much  of  it  as  is  easily 
detachable.  The  wound  should  not  be  drained,  for  drainage  implies 
infection,  and  this  means  death.  If  the  respiratory  obstruction  is 
relieved  in  time,  recovery  follows.  Olivier  (1912)  has  studied  the 
results  of  42  thymectomies;  of  the  15  deaths,  7  w^ere  not  due  to  the 
operation,  and  8  were  attributed  to  the  secondary  tracheotomy.  He 
concludes  that  subtotal,  subcapsular  thymectomy  is  the  best  treat- 
ment. 

SURGERY  OF  THE  ESOPHAGUS. 

Foreign  Bodies. — There  are  three  points  at  which  a  foreign  body 

is  apt  to  be  arrested:  (1)  At  the  level  of  the  cricoid  cartilage;  (2) 
where  the  left  bronchus  crosses  the  esophagus;  (3)  at  the  cardiac 
orifice  of  the  stomach.  All  sorts  of  things  may  be  swallowed:  chil- 
dren's playthings,  false  teeth,  pieces  of  bone,  and  in  the  insane,  even 
spoons,  forks,  etc.  Large  bodies  usually  are  arrested  in  the  pharynx, 
and  often  may  be  extracted  with  the  finger.  Bodies  with  sharp  prongs 
may  catch  in  the  esophageal  wall  at  any  point,  and  much  damage  may 
be  done  by  forcible  attempts  at  extraction. 

The  diagnosis  depends  on  the  history,  which  in  infants  and  the  insane 
may  be  very  uncertain;  on  the  presence  of  dysphagia;  and  on  the 
results  of  examination  with  esophageal  instruments  and  the  .r-ray. 
It  is  important  to  make  the  diagnosis  as  soon  as  possible,  before  inflam- 
matory softening  or  perforation  of  the  esophageal  wall  occurs.  Do 
not  postpone  thorough  examination  until  the  next  day,  thinking  the 
diagnosis  will  be  easier  then.  It  will  not  be.  The  esophagoscope 
should  be  employed  whenever  available,  and  if  used  early,  before 
the  mucous  secretion  is  excessive,  the  foreign  body  usually  can  be 
seen.  This  is  an  instrument  analogous  to  the  bronchoscope  and 
cystoscope.  It  is  very  much  safer  in  skilled  hands  than  the  insertion 
of  a  bougie,  but  this  may  be  the  only  instrument  obtainable. 


694 


SURGERY  OF   THE  FACE,   MOUTH,   AND  NECK 


Treatment. — By  means  of  an  esophagoscope  and  the  special  instru- 
ments employed  with  it,  one  skilled  in  the  use  of  such  apparatus 
frequently  will  be  able  to  extract  the  foreign  body  under  the  control 
of  the  eye.  If  this  is  not  possible,  the  surgeon  must  employ  the  older 
and  less  satisfactory  method  of  introducing  an  esophageal  forceps, 
probang,  or  coin-catcher  and  thus  endeavoring  to  remove  the  foreign 
body  by  the  sense  of  touch.  A  general  anesthetic  is  required.  A  coin 
usually  lies  transversely  in  the  esophagus,  and  may  be  caught  by  a 


Fig.  734. — Forceps  for  removing  foreign  bodies  from  the  esophagus. 

forceps  whose  blades  open  in  this  direction  (Fig.  734).  If  the  coin 
lies  very  far  down  in  the  esophagus  the  old  fashioned  "coin-catcher" 
(Fig.  735)  may  be  more  useful.  Occasionally  a  lodged  foreign  body 
may  be  advantageously  pushed  on  into  the  stomach.  It  is  not  safe 
to  make  violent  or  too  prolonged  efforts  at  extraction,  especially 
when  more  than  thirty-six  hours  have  elapsed.  When  all  reasonable 
efforts  have  failed,  or  at  once  if  the  nature  of  the  impacted  body 
forbids  attempts  at  extraction  through  the  mouth,  the  surgeon  should 


Fig.  735.- 


-Esophageal  instruments:  1,  Olive  tipped  bougie;  2,  horse-hair  probang ; 
3,  coin-catcher;  4,  esophageal  forceps. 


resort  to  external  esophagotomy  if  the  foreign  body  is  well  above  the 
cardiac  orifice;  if  impacted  at  the  latter  site,  extraction  should  be 
attempted  by  gastrotomy  (p.  876).  Under  the  best  modern  methods 
it  might  be  possible  to  perform  transpleural  esophagotomy. 

External  Esophagotomy. — Through  an  incision  along  the  anterior 
border  of  the  left  sterno-mastoid,  with  division  or  downward  dis- 
placement of  the  omo-hyoid,  the  esophagus  is  exposed  behind  the 
trachea  and  on  the  median  side  of  the  great  vessels    It  should  be  freely 


SURGERY  OF   THE  h'SOI'llACUS  095 

separated  from  the  surrounding  tissues,  and  incised  on  a  sound  passed 
from  the  mouth,  after  pulling  it  up  into  the  wound  and  isolating  it 
with  gauze.  The  foreign  body  is  then  extracted  with  finger  or  for- 
cei)s.  The  incision  in  the  esophagus  is  tightly  sutured  with  at  least 
two  rows  of  chromic  gut  sutures,  and  a  drainage  tube  is  passed  down 
to  the  site  of  suture,  and  is  not  removed  for  a  week.  The  remainder 
of  the  wound  is  closed  in  layers.  No  food  should  be  swallowed  for  a 
week  or  ten  days;  rectal  feeding  should  be  employed,  especially  saline 
solution  as  in  peritonitis,  but  in  the  case  of  very  weak  patients  food 
may  be  introduced  into  the  stomach  by  a  stomach  tube.  The  prog- 
nosis is  good  if  the  foreign  body  has  been  removed  within  the  first 
thirty-six  hours. 

Stricture  of  the  Esophagus  usually  results  from  lye  burns,  and  is 
especially  frequent  in  small  children  who  drink  a  cupful  of  the  nice 
white  Huid,  mistaking  it  for  milk.  It  may  occur  also  in  adults,  from 
ingestion  of  corrosive  poisons.  Symptoms  of  stricture  may  not  develop 
for  several  months  after  the  accident.  Sometimes  they  appear  rather 
suddenly,  but  usually  there  is  a  gradual  but  progressive  increase  in 
dysphagia,  at  first  for  solids,  then  for  liquids,  and  finally  regurgitation 
occurs  through  the  nostrils  as  soon  as  food  is  swallowed.  In  time  a 
pouch  may  form,  and  then  regurgitation  may  not  occur  for  half  an 
hour  or  more  after  food  is  ingested.  Any  inflammatory  attack  is  apt 
to  produce  complete  obstruction.  Weight  is  constantly  lost,  and 
emaciation  may  become  extreme.  There  is  a  decided  tendency  to 
bronchial  and  pulmonary  disease,  owing  to  regurgitation  of  decaying 
food,  and  death  may  occur  from  such  intercurrent  malady. 

Diagnosis. — The  diagnosis  is  made  from  the  history  of  the  accident, 
from  the  symptoms,  and  from  examination  of  the  esophagus.  This 
should  be  done  by  the  esophagoscope;  but  if  this  is  not  available, 
an  olive-tipped  bougie  (Fig.  735)  may  be  passed  ver}'  gently  and 
cautiously;  and  the  existence  of  a  stricture  and  its  site  may  be  thus 
determined.  The  x-ray  will  detect  the  existence  of  a  pouch  if  this 
is  filled  with  bismuth  gruel. 

Treatment. — 1.  If  the  stricture  is  easily  permeable  to  liquid  food, 
it  usually  will  be  possible  to  secure  passage  of  a  bougie,  especially  if 
this  is  done  under  control  of  vision  through  the  esophagoscope. 
Many  strictures  impermeable  to  blind  instrumentation  are  not  imper- 
meable with  esophagoscopy.  The  danger  of  perforation,  especially  if 
there  is  a  thin  walled  pouch,  always  should  be  kept  in  mind.  Such 
an  accident  generally  results  fatally  in  a  few  days  from  septic  pneu- 
monia or  mediastinitis.  If  a  bougie  can  be  passed,  gradual  dilatation 
often  is  possible,  as  in  the  case  of  permeable  urethral  stricture;  but 
hazardous  as  is  the  employment  of  any  force  in  urethral  instrumenta- 
tion, it  is  absolutely  harmless  compared  to  its  use  in  esophageal  work. 
The  safest  esophageal  sound,  when  one  is  used  without  the  esophago- 
scope, is  the  olive-tipped  bougie,  but  it  is  relatively  safe  only  because 
of  its  size.  The  smaller  the  stricture,  the  more  flexible  should  be  the 
instrument.     Gradual  dilatation  may  be  aided  by  internal  esopha- 


096  SURGERY  OF   THE  FACE,   MOUTH,   AND  NECK 

gotomy  througli  the  esophagoscope,  the  edge  of  the  stricture  being 
divided  under  full  view.  Subsequent  dilatation  always  should  be 
conducted  under  control  of  esophagoscopy. 

2.  If  the  stricture  is  impermeable  to  instruments,  the  treatment 
depends  somewhat  upon  the  amount  of  nourishment  the  patient  can 
take.  If  sufficient  nourishment  is  taken  to  maintain  weight,  various 
expedients  may  be  tried  to  get  through  the  stricture.  The  patient 
may  be  made  to  swallow  a  silver  l)all  (Abercrombie,  1830)  or  per- 
forated shot  (Socin,  1889)  attached  to  a  string;  after  resting  on  the 
stricture  for  some  hours  these  may  pass  through,  and  thus  from  day 
to  day  larger  balls  may  be  used,  until  a  bougie  can  be  passed.  These 
methods  are  not  more  effective  than  esophagoscopic  instrumentation, 
but  may  be  tried  when  this  is  not  available.  External  esophagotomy 
rarely  can  be  recommended,  e\en  when  the  upper  end  of  the  stricture 
is  accessible  through  the  neck.  It  is  not  likely  that  this  method  will 
be  successful  when  esophagoscopy  has  failed,  and  it  cannot  be  known 
that  the  stricture  does  not  extend  all  the  way  down  to  the  cardiac 
orifice.  If  weight  is  being  lost,  it  is  useless  to  postpone  a  resort  to 
gastrostomy  (p.  877).  When  the  stomach  is  opened,  attempts  may 
be  made  to  pass  an  instrument  through  the  stricture  from  below, 
and  these  occasionally  are  successful.  But  if  the  patient  is  very  weak 
it  is  better  not  to  prolong  the  operation,  but  merely  to  establish  an 
opening  in  the  stomach  as  rapidly  as  possible.  Stamm's  or  Senn's 
method  is  the  best  for  these  cases.  It  usually  happens  that  the  stric- 
ture becomes  permeable  after  the  esophagus  has  had  a  rest  for  some 
weeks,  while  food  is  being  introduced  through  the  gastric  fistula. 
This  is  analogous  to  the  usual  course  of  impermeable  urethral  stric- 
tures after  the  performance  of  Cock's  operation  (p.  1026).  When  the 
stricture  becomes  permeable,  a  string  may  be  passed  through  it  from 
the  mouth;  then  by  extracting  the  other  end  through  the  gastric 
fistula,  the  stricture  may  be  cut  by  a  sawing  motion,  while  the  esopha- 
gus is  kept  taut  to  prevent  damage  to  its  walls  (Abbe's  method,  1893) ; 
or  the  surgeon  may  adopt  von  Hacker's  method  (1894)  of  retrograde 
dilatation  by  drawing  through  the  stricture  gradually  increasing 
sizes  of  rubber  tubing,  at  intervals  of  a  few  davs  ("Sondierung  ohne 
Ende"). 

3.  If  the  stricture  remains  impermeable  even  after  gastrostomy, 
there  are  still  several  plans  of  treatment  which  may  be  adopted. 
Maffei  (1906)  in  two  cases  successfully  exposed  the  esophagus  by  the 
transpleural  route,  and  found  that  the  stricture  became  permeable 
as  soon  as  he  had  released  the  peri-esophageal  adhesions ;  the  esophagus 
was  not  opened  at  all.  Roux  (1907)  and  Herzen  (1908)  have  formed 
an  artificial  esophagus  by  transplanting  beneath  the  skin  of  the 
sternum  a  loop  of  the  upper  jejunum,  excluded  from  the  intestinal 
tract.  This  is  to  be  attached  above  to  the  cervical  esophagus,  and 
below  to  the  stomach.  Herzen's  name  for  this  delicate  procedure, 
which  is  completed  in  several  sittings,  is  "ante-thoracic  esophago- 
jejuno-gastrostomy."     Willy  Meyer  (1913)  has  followed  Jianu  and 


HVRCERY  OF  THE  ESOl'llAGUS  ()07 

Uocpkc  ill  iitiliziii»i;  a  llii]>  t'roiii  the  <:;r('at('r  ciirNiitiin' ol'  (he  stoiiiacli, 
to  ('(Histriict  a  now  ])rc-stt'riial  (•s()|)lia<,nis. 

Congenital  Imperforation  of  the  Esophagus  is  a  rare  iiialtorination 
ill  wliicli  tlif  gastric  end  of  the  eso]jlia^ns  usually  empties  into  the 
bronchus,  and  the  pharyngeal  end  terminates  in  a  l)lind  pouch.  Tiie 
hal)\'  sutlers  from  recurring  attacks  of  sutt'ocation  due  to  regurgi- 
tation of  gastric  contents  into  the  air  passages;  food  swallowed  is  at 
once  regurgitatefl.  The  best  treatment  is  jjerforinance  of  jejiino.S'toniy 
(]).  878),  for  the  purpose  of  introducing  nourishment,  as  advised  by 
Demoulin  (1904).  Should  the  infant  survive  (which  is  unusual) 
treatment  as  for  impermeable  stricture  of  the  esophagus  should  be 
attcm])tcd  later. 

Diverticula  of  the  Esophagus  may  be  congenital  or  acquired. 
The  ac(|uirc(l  diverticula  are  due  either  to  traction  from  without 
(usually  from  adhesions  to  bronchial  lymph  nodes,  etc.),  or  to  pressure 
from  within.  The  irariion  diverticula  rarely  produce  symi)toms,  as 
their  lumen  is  oblique  or  horizontal  and  the  orifice  is  directed  down- 
ward (Zenker,  1878);  food  is  not  apt  to  collect  in  them,  and  often 
they  are  found  unexpectedly  at  autopsy.  But  occasionally  during 
life  perforation  occurs.  Pressure  diverticula,  well  studied  by  Halstead 
in  1904,  constantly  produce  symptoms  during  life,  from  accumula- 
tion and  regurgitation  of  food.  Sometimes  during  meals  a  palpable 
tumor  appears  in  the  left  side  of  the  neck,  and  can  be  emptied  by 
pressure.  Often  the  earlier  part  of  a  meal  will  be  swallowed  more 
easily  than  the  latter  part,  because  gradual  filling  of  the  pouch  causes 
obstruction  of  the  esophagus.  The  pouch  is  found  most  often  to 
spring  from  the  posterior  wall  of  the  esophagus  in  the  median  line, 
just  below  the  pharynx.  A  bougie  sometimes  will  be  arrested  in  the 
pouch,  and  sometimes  will  pass  on  into  the  stomach,  and  thus  the 
condition  may  simulate  a  spasmodic  stricture.  But  if  one  bougie 
is  arrested  in  the  pouch,  it  may  be  possible  to  pass  another  alongside 
of  it  into  the  stomach.  The  diagnosis  is  aided  by  esophagoscopy  and 
by  the  use  of  the  x-ray  after  filling  the  pouch  wuth  bismuth  gruel. 

Treatment. — If  the  diverticulum  is  accessible  from  the  neck,  it  should 
be  exposed  from  the  left  side,  and  excised.  The  stump  is  treated  as 
the  appendix  stump  (p.  857),  and  the  wound  treated  as  in  external 
esophagotomy  (p.  G94). 

Dilatation  of  the  Esophagus,  as  a  whole,  usually  is  secondary  to 
what  has  been  described  as  cardiospasm,  w^hich  is  now  believed  to  be 
not  a  spastic  condition  of  the  cardiac  orifice  of  the  stomach,  but  of 
the  esophagus  just  above  the  cardia.  The  cause  of  the  "cardiospasm" 
has  not  always  been  determined,  but  in  some  cases  gross  esophageal 
lesions  (ulcer,  carcinoma,  etc.)  have  been  found. 

Symptoms. — The  symptoms  are  those  of  slowly  oncoming  and  never 
entirely  complete  obstruction  to  food.  In  the  early  stages  there  is 
a  feeling  of  fulness  after  eating,  with  an  uneasy  sensation  in  the 
epigastrium  or  behind  the  sternum;  the  patient  eats  very  slowly, 
and  requires  much  liquid  to  wash  the  food  down;  final  entrance  of 


698  SURGERY  OF   THE  FACE,   MOUTH,   AND  NECK 

food  to  the  stomach  may  be  accomphshed  only  after  the  patient  has 
retired  to  a  corner  and  urged  the  food  down  by  deep  breathing,  gulp- 
ing, or  curious  contortions  of  the  arms  and  body.  Later,  regurgitation 
occurs  immediately  after  swallowing;  but  when  full  dilatation  has 
developed  food  may  be  retained  for  several  hours.  The  regurgitated 
food  is  not  sour,  as  it  would  be  if  vomited  after  lying  in  the  stomach. 

Diagnosis. — Diagnosis  is  based  on  the  symptoms,  and  on  the  exclu- 
sion of  organic  stricture  by  esophagoscopy  or  by  passage  of  a  bougie. 
A  bougie  may  be  arrested  near  the  cardiac  orifice,  but  usually  passes 
through  after  temporary  arrest.  A  skiagraph,  made  after  ingestion 
of  bismuth  gruel,  also  is  helpful. 

Treatment. — The  most  satisfactory  treatment  is  forcible  divulsion 
of  the  cardia.  This  can  be  done  by  instruments  passed  by  mouth,  as 
in  the  methods  of  Sippy  and  of  Plummer.  The  apparatus  consists 
of  a  rubber  bag  about  10  cm.  long,  encased  in  a  silk  bag  which  limits 
the  possible  distention  to  a  circumference  of  15  cm.  Dilatation  is 
produced  by  an  air-pump.  The  treatment  usually  must  be  repeated 
several  times  before  complete  relief  is  secured.  No  anesthetic  is 
necessary.  In  some  cases  divulsion  of  the  cardia  may  be  done  after 
gastrostomy. 

Carcinoma. — Carcinoma  is  the  most  frequent  disease  of  the  esoph- 
agus. It  occurs  oftenest  in  males,  in  the  decline  of  life.  About  50 
per  cent,  of  cases  are  near  the  cardia,  40  per  cent,  at  the  bifurcation 
of  the  trachea,  and  only  10  per  cent,  at  the  cricoid  cartilage.  It 
probably  often  develops  in  an  ulcer  or  erosion.  Its  onset  is  insidious, 
but  when  once  symptoms  develop,  they  progress  rapidly.  The  chief 
characteristic  is  increasing  difficulty  in  deglutition,  for  which  no  cause 
can  be  found  in  the  patient's  clinical  history.  Syphilitic  stricture  is 
rare  but  must  be  excluded.  The  diagnosis  from  aortic  aneurysm 
often  is  exceedingly  difficult.  In  carcinoma  very  early  and  great 
enlargement  of  the  bronchial  lymph  nodes  may  occur;  there  often  are 
pressure  palsies  of  the  recurrent  laryngeal  or  sympathetic  nerves;  and 
dyspnea  may  exist.  Referred  pain  is  common,  and  erosion  of  the 
vertebrae  and  even  paraplegia  may  develop  before  symptoms  of 
esophageal  obstruction  are  marked.  Pulmonary  complications  are 
frequent.  Passage  of  a  bougie  may  provoke  hemorrhage.  Esopha- 
goscopy is  important.  The  prognosis  is  very  bad.  Death  u.sually 
occurs  in  a  year  from  the  date  of  diagnosis. 

Treatment. — When  thoracic  surgery  becomes  better  developed,  and 
especially  by  the  use  of  anesthesia  by  intratracheal  insufflation,  it  will 
be  possible  to  explore  the  seat  of  disease,  with  the  hope  of  doing 
a  radical  operation.  This  has  been  accomplished  once  successfully, 
by  Torek  (1913).  In  most  cases  only  the  palliative  operation  of  gas- 
trostomy is  successful,  but  this  should  not  be  employed  so  long  as 
liquids  can  be  swallowed.  Whenever  possible,  before  this  operation 
is  done,  the  intestinal  tract  should  be  cleared  of  the  masses  of  stagnant 
feces  usually  present. 


CHAPTER   XX. 

SURGERY  OF  THE  BREAST,  THE  CHEST  WALL,  THE 
LUNGS,  AND  THE  DIAFHI^AGM. 

SURGERY  OF  THE  BREAST. 

Congenital  Anomalies. — The  only  one  of  these  that  is  of  much 
surgical  interest  is  the  existence  of  supernumerary  breasts,  a  con- 
dition known  as  poJymastia.  Either  sex  may  be  affected,  but  it  is 
said  to  be  slightly  more  common  in  males.  The  extra  glands  may  be 
situated  almost  in  any  part  of  the  trunk,  most  often  near  the  axilla 
or  groin  (Fig.  730),  or  in  a  line  joining  these  two  sites.  The  accessory 
glands  may  be  of  various  sizes.  Sometimes  only  a  supernumerary 
nipple  is  present  (polythelia),  (Fig.  737),  and  sometimes  a  mass  of 
mammary  tissue  without  a  nipple  exists  in  the  subcutaneous  tissues. 
In  men  this  resembles  a  lipoma;  but  in  women  its  true  nature  is 
revealed  by  its  increase  in  size  during  menstruation,  or  pregnancy, 
or  lactation.  Any  supernumerary  mamma  which  causes  annoyance 
should  be  excised. 


ll"'' 

1 

^^^^H 

9 

^^B||C 

Fig.  736. — Supernumerary  mamma  (or  lipoma?)  in  adult  male.  Since  puberty  has 
had  this  mass  which  at  times  used  to  discharge  a  little  whitish  fluid.  Note  the  nipple- 
like projection,  but  absence  of  pigmentation.     Episcopal  Hospital. 

Affections  of  the  Nipple. — Sometimes  a  nipple  fails  to  develop 
properly,  especially  where  tight  underclothing  is  constantly  worn. 
During  pregnancy  care  should  be  taken  to  favor  its  development 
by  drawing  it  out,  gently;  and  it  should  be  further  prepared  for 
suckling  by  frequent  cleansing  and  application  of  astringent  washes, 
of  which  none  is  better  than  dilute   alcohol.      During    lactation, 


roo 


SURGERY  OF  THE  BREAST 


not  only  should  the  condition  of  the  infant's  mouth  be  watched, 
but  the  nii)ple  should  be  washed  with  warm  water  and  castile  soap 
before  and  after  suckling,  and  if  any  tendency  to  irritation  exists 
it  should  be  dustcfl  with  boric  acid  or  borated  talcum  powder  after 
cleansing  after  each  act  of  nursing.  Fissures  and  excoriatiuris  of  the 
nipple,   which   are   extremely   painful   and    interfere   with   suckling, 

should  be  treated  by  unremit- 
ting attention  to  cleanliness. 
The  use  of  a  nipple  shield  or 
breast  pump,  so  as  to  prevent 
direct  contact  of  the  child's 
mouth,  is  necessary,  and  in 
most  cases  the  act  of  suckling 
must  be  discontinued  tempor- 
arily. The  excoriations  and 
fissures,  after  gentle  cleansing, 
should  be  painted  with  dilute 
tincture  of  iodin  (1  part  to  5 
of  water),  or  a  weak  glycerite 
of  tannin,  and  then  dusted  with 
boric  acid  powder.  The  use  of 
ointments  is  injurious. 

Acute  Mastitis. — Though  in- 
flammation of  the  breast  occa- 
sonally  develops  in  the  newborn, 
and  in  boys  and  girls  at  puberty, 
it  occurs  oftenest  in  nursing  women,  being  in  most  cases  an  ascending 
infection  from  the  nipple  by  way  of  the  ducts  or  the  lymphatics.  It 
is  most  frequent  in  primiparse,  especially  in  those  with  poorly  developed 
nipples,  which  have  received  insufficient  attention  during  pregnancy. 
It  occurs  most  often  within  a  few  days  of  delivery,  or  not  until  the 
end  of  lactation. 

Acute  mastitis  is  characterized  by  the  usual  signs  of  inflammation, 
which  are  confined  in  almost  all  instances  to  one  or  more  lobes  of  the 
gland.  Diffuse  inflammation  is  rare.  The  regions  affected  feel 
tough  and  doughy,  and  tenderness  is  not  very  marked.  The  skin  is 
unaltered  and  moves  freely  over  the  breast.  There  is  a  heavy  feel- 
ing, with  dull  pain,  and  occasionally  shooting  pains.  In  a  puerperal 
woman  this  stage  is  described  as  "caked  breast,"  because  of  the  accu- 
mulation and  inspissation  of  the  milk  owing  to  obstruction  of  the 
galactophorous  ducts  b}'  the  inflammatory  changes. 

Treatment. — Treatment  consists  in  attention  to  the  nipple,  which 
may  be  fissured  or  excoriated,  and  to  the  patient's  general  health. 
The  child  should  not  be  allowed  to  suckle  from  the  affected  breast 
until  resolution  is  complete.  Daily  light  massage  of  the  area  affected 
usually  is  efficacious  in  overcoming  the  stagnation  and  promoting 
resolution  without  suppuration.  Some  ointment  with  lanolin  as 
a  basis  should  be  used  in  connection  with  the  massage.     In  the 


Fig.  737. — Polythelia;  a  supernunifrary 
nipple  near  right  nipple.  Orthopgedic  Hos- 
pital. 


MAMMARY  ABSCESS 


701 


intervals  the  breast  should  he  covered  with  heiladoiina  and  mercury  or 
other  sorhet'acient  ointment,  and  well  supported  with  a  compressory 
handa;i;e  or  hinder.  Meantime  a  breast  pump  nnist  l)e  emi)loyed. 
Another  valuable  aid  in  resolution  is  passive  hyperemia,  according 
to  Bier's  method,  with  a  cupping  glass  applied  over  the  nipple,  as 
originally  introduced  by  (Miassaignac. 

Mammary  Abscess. — Mammary  abscess  usually  develops  as  a 
sequel  of  stagnation  mastitis  (caked  breast).  The  area  affected 
becomes  more  tender;  dusky  redness  appears  in  the  skin;  this  becomes 
adherent  to  the  deeper  structures;  and  the  abscess  is  ready  to  be 
oi)ene(l  (Fig.  7.SS).  Before  this  occurs,  however,  destruction  of  the 
mannnary  tissue  may  be  very 
extensive,  and  it  is  very  im- 
portant to  recognize  the  onset 
of  suppuration  as  early  as  pos- 
sible. The  fluid  expressed  from 
the  nipple  by  massage,  in  the 
stage  of  caked  breast,  should  be 
collected  from  time  to  time  on 
gauze.  The  milk  will  be  ab- 
sorbed; but  if  there  is  any  pus 
in  the  fluid,  it  will  remain  on 
the  surface  of  the  gauze  and 
stain  it  yellow.  This  is  known 
as  Budin's  sign.  As  soon  as 
suppuration  [is  suspected,  the 
inflamed  area  should  be  incised. 
This  incision  should  be  made 
directly  over  the  area  affected, 
and  in  a  line  radiating  from 
the  nipple,  so  as  to  injure  as 
few  of  the  milk  ducts  as  possible 
and  thus  decrease  the  chance  of  a 
lacteal  fistula  developing.  The  earlier  and  more  freely  this  incision 
is  made,  the  less  danger  there  is  of  the  pus  burrowing  among  the 
glandular  tissue.  If  delayed,  various  pockets  of  pus  will  be  found, 
and  these  will  have  to  be  broken  open  by  the  finger  to  ensure 
free  drainage.  Tube  drainage  is  desirable  until  the  discharge  of  pus 
ceases.  An  abundant  dressing  of  hot  moist  gauze  (soaked  in  boric 
acid  or  normal  saline  solution)  is  required  to  absorb  the  discharge. 
After  drainage  is  discontinued  the  wound  closes  rapidly  in  most  cases, 
if  incision  has  been  made  early  enough;  if  it  has  been  delayed  or  not 
sufficiently  free,  secondary  abscesses  may  form.  Very  rarely,  when 
the  breast  is  riddled  with  abscesses  and  discharging  sinuses,  amputa- 
tion is  required. 

Chronic  mammary  abscess  is  not  very  rare;  it  may  be  subacute  or 
frankly  chronic.  The  former  usually  arises  during  lactation,  as  the 
result  of  an  unresolved  stagnation  mastitis;  or  after  an  imperfectly 


Fig.  738. — Abscess  of  left  breast  in  a 
primipara.  Age  twenty  years,  nursing  a 
baby  three  months  old.  Duration  of 
mastitis  ten  days.  Incised  and  drained  by 
tube;  in  nine  days  only  a  granulating  sur- 
face remained.     Episcopal  Hospital. 


702  SURGERY  OF  THE  BREAST 

drained  acute  abscess.  Those  which  develop  independently  of 
lactation  are  much  more  unusual,  and  may  be  due  to  suppuration  in 
a  hematoma  (from  trauma),  or  to  excoriations,  patches  of  eczema, 
etc.,  on  the  nipple  or  in  the  inframammary  fold.  The  .symptoms  are 
those  of  chronic  mastitis  (see  below),  but  the  yhysical  signs  resemble 
more  those  of  a  neoplasm  (p.  711),  and  the  diagnosis,  which  often  is 
impossible,  rests  on  the  history  of  the  case,  and  the  detection  of  some 
source  of  infection.  Treatment:  Exploratory  incision,  best  by  the 
submammary  incision  (p.  711),  usually  is  necessary  for  diagnosis; 
and  the  abscess  wall  which  often  is  thick  and  indurated,  should  then 
be  removed  in  entirety. 

Submammary  Abscess. — Suppuration  may  occur  in  the  cellular 
tissue  between  the  pectoral  muscle  and  the  breast.  Usually  this  is 
caused  by  an  abscess  in  a  deep  lying  lobe  of  the  mammary  gland, 
where  pointing  occurs  tlirough  the  deep  layer  of  superficial  fascia 
in  which  the  gland  lies,  instead  of  tlirough  the  overlying  skin;  indeed, 
prolongations  of  the  gland  may  extend  normally  into  the  retro- 
mammary space.  In  a  few  cases,  however,  submammary  abscess  is 
secondary  to  axillary  lymphadenitis  or  to  diseases  of  the  pleura, 
caries  of  the  ribs,  etc.,  which  usually  are  tuberculous  in  nature.  The 
diagnosis  of  submammary  abscess  is  not  always  easy;  the  gland  is 
prominent,  raised  away  from  the  chest  by  the  suppuration  beneath ; 
but  owing  to  the  deep  seat  of  the  suppuration  the  ordinary  physical 
signs  of  an  abscess  may  not  be  present.  The  abscess  may  simulate 
a  small  hard  tumor,  especially  as  axillary  adenitis  often  is  present. 
Treatment  consists  in  evacuation  of  the  pus  by  a  curved  incision 
beneath  the  lireast,  with  free  drainage  until  the  discharge  ceases. 

Subpectoral  Abscess. — See  p.  730. 

Chronic  Mastitis. — In  addition  to  the  acute  infectious  mastitis, 
already  described  as  most  frequent  in  puerperal  women,  there  occurs 
a  form  of  circumscribed  subacute  or  chronic  mastitis,  probably  also 
infectious  in  origin,  in  women  at  almost  any  age,  but  usually  in  those 
between  twenty  and  thirty,  or  in  those  approaching  the  menopause, 
and  among  the  unmarried  nearly  as  frequently  as  in  those  who  have 
borne  children.  They  come  to  the  surgeon  complaining  of  a  painful 
and  tender  area  in  the  breast,  about  which  they  not  infrequently 
seem  unduly  alarmed.  Examination  shows  slight  or  no  enlargement 
of  the  breast,  and  palpation  of  the  gland  with  the  hand,  pressing  it 
flat  against  the  chest  wall,  makes  it  clear  that  there  is  no  tumor 
present.  If  the  gland  is  examined  between  the  thumb  and  fingers, 
one  or  more  irregularly-shaped,  ill  defined  masses  may  be  felt;  these 
usually  seem  to  radiate  from  the  nipple,  and  undoubtedly  are  in  the 
glandular  tissue.  The  overlying  skin  is  unaltered,  and  the  breast 
moves  freely  upon  the  chest  wall.  The  mass  may  be  exquisitely 
tender,  and  the  seat  of  shooting  or  neuralgic  pains.  The  overlying 
skin  may  be  highly  hyperesthetic.  To  such  a  condition  in  neurotic 
women,  the  term  inastodynia  or  neuralgia  of  the  breast  has  been  applied. 
This  is  the  "  irritable  tumor  of  the  breast"  of  Sir  Astley  Cooper  (1829), 


GALACTOCELE  703 

thou«,fli  it  is  also  i)()ssihlr  that  sucli  a  coiulition  iiiif^lit  hv  caused  l)y  a 
false  neuroma  (p.  293)  as  iu  other  ])orti()ns  of  the  body.  Pain  referred 
to  the  breast  in  eases  of  intereostal  neuralgia  should  not  l)e  confused 
with  true  mastodynia.  In  most  ciuses  of  luaModynia  both  hreasia  are 
affected,  but  only  one  out  of  a  number  of  such  lumps  may  give 
symptoms.  They  may  produce  symptoms  during  menstruation  or 
pregnancy,  and  not  at  other  times. 

The  cause  of  these  changes  is  obscure,  and  the  subject  is  not  much 
clarified  by  the  various  hypotheses  which  have  been  advanced.  If 
the  woman  has  borne  children,  the  natural  assumption  is  that  these 
masses  are  the  result  of  clianges  occurring  during  lactation;  they  may 
be  the  remains  of  an  area  of  stagnation  mastitis  (caked  breast)  which 
was  so  sHght  as  to  have  been  overlooked  at  the  time.  In  virgins, 
it  may  be  assumed  that  the  breast  has  been  subject  to  forgotten 
trauma;  or  that  its  condition  is  connected  with  some  functional 
derangement  of  the  pelvic  organs. 

The  pathological  anatomy  of  the  condition  is  practically  unknown, 
as  operation  has  been  undertaken  very  seldom.  Lecene  (1911) 
examined  a  fragment  of  tissue  from  such  a  specimen,  and  found 
lesions  which  corresponded  to  a  functional  hypertrophy  of  the  acini, 
w^ith  lymphatic  stasis,  and  slight  degree  of  congestion;  he  concluded 
that  they  were  trophic  or  vasomotor  in  origin,  and  in  no  way  truly 
inflammatory. 

The  clinical  course  of  the  disease  is  various.  Usually  the  symptoms 
subside  under  conservative  treatment,  and  the  masses  do  not  enlarge 
or  give  any  other  evidence  of  their  presence;  in  many  cases  they 
almost  disappear.  In  some  cases,  however,  a  cystic  transformation 
supervenes,  the  pathogenesis  of  wdiich  is  uncertain;  probably  it  is 
neoplastic  in  character,  and  not  due  to  inflammatory  compression 
of  the  gland  ducts  (p.  712). 

Treatment. — Firm  support,  by  bandaging  or  binder,  or  even  by 
adhesive  plaster  strapping,  should  be  provided,  unless  the  tenderness 
is  so  excessive  as  to  render  this  impossible.  Belladonna  and  mercury, 
compound  iodin  or  ichthyol  ointment,  applied  to  the  breast,  leaving 
the  nipple  uncovered,  is  useful  in  relieving  tenderness.  When  tender- 
ness sul3sides,  gentle  massage  should  be  given.  The  condition  of  the 
pelvic  organs  should  be  determined,  and  suitable  treatment  insti- 
tuted. Tonics,  good  food,  and  general  hygienic  measures  should  not 
be  neglected. 

In  addition  to  this  circumscribed  form  of  chronic  mastitis,  some 
writers  recognize  a  diffuse  chronic  mastitis.  I  have  discussed  this 
subject  at  p.  709. 

Galactocele. — Closely  related  pathologically  with  chronic  mastitis 
is  the  condition  described  as  galactocele,  formerly  considered  a 
retention  cyst  of  the  breast.  The  cyst  wall,  however,  is  not  composed 
of  secreting  cells,  but  is  formed  by  a  condensation  of  surrounding 
connective  tissues.  Lecene  (1911)  holds  that  it  is  merely  a  chronic 
abscess  into  which  milk  ducts  have  opened  secondarily;  others,  with 


704  SURGERY  OF  THE  BREAST 

less  probability  as  it  seems  to  me,  contend  that  the  primary  con- 
dition was  dilatation  of  the  lactiferous  tubules,  and  that  the  cyst 
is  formed  by  their  rupture  into  the  surrounding  tissues.  Galactocele 
is  quite  rare,  and  occurs  most  often  during  lactation.  A  small  lump 
forms  quite  suddenly;  usually  it  is  in  the  region  of  the  areola,  but 
may  be  more  deeply  seated.  Sometimes  several  cysts  exist.  The 
mass  is  not  tender  or  painful,  feels  semi-cystic,  and  is  quite  movable 
beneath  the  skin  and  on  the  underlying  pectoral  fascia.  In  many 
cases  pressure  on  the  swelling  causes  milk  to  exude  from  the  nipple, 
and  the  cyst  may  thus  be  emptied.  In  other  cases  its  contents  become 
inspissated,  and  resemble  butter  or  cheese,  when  there  may  be  pitting 
on  pressure,  which  is  a  very  characteristic  sign.  Lacteal  calculi  have 
been  described  in  some  of  these  cases,  but  modern  writers  consider 
the  reports  apocryphal. 

Treatment. — A  galactocele  should  be  excised,  and  the  wound 
sutured.  Incision,  followed  by  packing,  is  followed  by  tedious  cure, 
and  the  cicatrix  is  more  conspicuous. 

Tuberculosis  of  the  Breast  is  a  rare  affection.  It  occurs  almost 
solely  in  women  from  thirty  to  fifty  years  of  age,  usually  those  who 
have  borne  children.  The  infection  may  be  an  ascending  one  from 
the  nipple,  by  way  of  the  ducts  or  lymphatics;  may  be  hematogenous; 
or  may  arise  by  extension  from  an  adjacent  focus  in  the  ribs,  sub- 
mammary lymphatics,  or  pleura.  ]\Iany  scattered  nodules  may  be 
found,  or  one  or  two  large  masses.  The  tendency  toward  the  forma- 
tion of  cold  abscess  and  toward  spontaneous  fistulization  is  more 
common  in  the  latter  form.  Until  this  stage  is  reached  the  diagnosis 
is  nearly  impossible  clinically,  and  even  after  these  developments 
it  is  not  always  easy.  The  axillary  lymphatics  usually  are  enlarged. 
If  secondary  infection  follows  fistulization,  the  general  health  rapidly 
deteriorates. 

Treatment. — The  only  satisfactory  treatment  is  amputation  of 
the  breast,  and  extirpation  of  the  axillary  lymphatics.  The  operation 
resembles  that  for  carcinoma,  but  it  is  not  necessary  to  remove  the 
pectoral  muscles  unless  they  are  manifestly  diseased. 

Syphilis. — Syphilis  may  affect  the  skin  over  the  breast,  or  the 
mammary  gland  itself.  A  chancre  presents  the  same  characters 
here  as  elsewhere;  it  occurs  almost  exclusively  in  women  who  act  as 
wet-nurses  to  foundlings  or  other  infants  with  congenital  syphilis; 
the  lesions  may  be  multiple  and  often  both  breasts  are  affected. 
Prophylaxis  usually  is  possible,  and  a  syphilitic  child  never  should 
be  nursed  by  another  than  its  own  mother,  who  is  immune  to  infection 
in  this  way^  according  to  Colles's  law  (p.  998).  Secondary  lesions  of 
syphilis,  especially  mucous  yatches,  often  may  be  found  in  the  sub- 
mammary fold  when  not  visible  elsewhere.  Sometimes  in  this  stage 
of  syphilis  the  mammary  glands  become  swollen  and  painful,  the 
condition  being  known  as  diffuse  syphilitic  mastitis.  Gumma  is  the 
most  frequent  lesion  of  syphilis  which  affects  the  glandular  tissue 
of  the  breast.    It  is  quite  rare,  however,  and  is  difficult  to  distinguish 


TUMORS  OF   Tilt:  BREAST  705 

from  sonic  hciiij^n  tumors  imlt'ss  a  distinct  history  ot"  sypliiiis  can 
be  obtained,  or  the  Wasscrmann  test  is  positive,  or  when  the  bene- 
ficial cfVcct  of  antisyphiiitic  treatment  becomes  apparent.  Fortunately 
the  iodides  are  \-er\   rapidly  curative. 

Tumors  of  the  Breast. — The  subject  of  tumors  of  the  mammary 
f,dan<l  usually  is  a  difficult  one  for  the  student,  because  owing  to  the 
complexity  of  its  structure  the  tumors  growing  in  it  are  of  many 
diHerent  kinds  derived  from  epithelial  or  fibrous  tissues.  Thus 
there  may  be  adenomatous,  papillomatous,  epitheliomatous,  cystic, 
and  even  sarcomatous  tumors.  And  as  in  most  of  these  tumors  both 
the  epithelial  and  fibrous  elements  seem  to  participate  almost  equally 
in  the  blastomatous  .transformation,  it  is  rare  for  a  pure  adenoma, 
or  a  pure  fibroma  to  develop.  Instead  we  find  many  combinations 
of  fibrous,  adenomatous,  cystic,  papillomatous,  and  other  conditions. 
The  following  classification,  based  in  part  on  that  of  J.  Collins  Warren 
(1905),  seems  to  me  the  most  satisfactory.  The  relative  frequency 
of  the  different  growths  is  indicated  by  the  attached  percentages. 

Blast omatoid  Conditions 

(a)  P'ibro-adenomatosis,      .2  per  cent.  I  16  per  cent 

(6)  C\-st-adenomato.sis,   1.5.8  per  cent.  /        ^ 

Benign  Tumors 

1.  P'ibro-adenoma,  9.6  per  cent. 

/  \  T)    •  1     .   1  cu  /  Intracanalicular     1 

(a)  Periductal  fibroma  >    pericanalicular       \ 

(b)  Periductal  myxoma 

(c)  Periductal  sarcoma  j^  12  per  cent. 

2.  Cyst-adenoma,  2.4  per  cent. 

(a)  Fibro-cyst adenoma 

(b)  Papillary-cystadenoma 
.3.  Simple  Adenoma       j 

4.  Lipoma  | 

5.  Angeioma  [  1  per  cent. 

6.  Endothelioma 

7.  Enchondroma 

Malignant  Tumors 

1.  Sarcoma,         1  per  cent. 

2.  Carcinoma,  70  per  cent. 

(a)  Adenocarcinoma 

(6)  Solid-celled  Carcinoma 

1.  Scirrhous  Carcinoma  c  71  per  cent. 

2.  Carcinoma  Simplex 

3.  Medullary  Carcinoma 

(c)  Paget 's  Disease  of  the  Nipple 

(d)  Carcinomatous  Cyst 

Before  discussing  blastomas,  or  tumors  proper,  it  is  necessary  to 
say  something  of  certain  blastoniatoid  conditions  Avhich  occur  in  the 
breast.  The  general  characters  of  these  conditions  were  discussed 
in  Chapter  IV. 

In  the  mammary  gland  there  occur  lesions  the  true  nature  of  which 
is  still  in  much  dispute.  As  to  one  condition  especially,  while  it  may 
be  said  that  surgeons  acknowledge  its  existence  and  are  agreed  on 
45 


706  SURGERY  OF   THE  BREAST 

its  clinical  features;  and  while  pathologists  agree  on  the  histological 
picture;  yet  the  former  cannot  agree  on  a  name  which  they  consider 
descriptive,  and  the  latter  cannot  agree  on  the  interpretation  of 
what  they  see  under  the  microscope.  This  condition  is  known  in 
some  quarters  by  the  name  "chronic  cystic  mastitis."  Another 
condition  the  classification  of  which  is  disputed,  is  described  as 
''idiopathic  hypertrophy"  of  the  breasts.  Now  when  one  looks  at 
the  classification  of  tumors  given  above,  he  sees  that  under  the  benign 
growths  the  two  main  types,  which  are  fibro-epithelial  in  character, 
are  (1)  Fibro-adenoma,  and  (2)  Cystadenoma.  Were  he  to  look 
around  for  blastomatoid  conditions  in  his  patients  corresponding 
to  these  tumors,  he  would  find  that  such  conditions  actually  occur; 
and  it  would  be  a  matter  of  surprise  that  no  one  had  previously 
recognized  that  idiopathic  hypertrophy  of  the  breasts  corresponds 
to  a  fibro-adenomatosis,  and  that  chronic  cystic  mastitis  corresponds 
to  a  cystadenomatosis.  Let  us  look  then  at  these  two  conditions 
more  narrowly,  and  see  what  they  are: 

Fibro-adenomatosis. — Diffuse  or  "idiopathic  hypertrophy"  of  the 
breasts  may  appear  first  during  pregnancy;  but  the  disease  in  most 
cases  affects  virgins  soon  after  the  age  of  puberty.  Albert  (1910) 
has  collected  18  cases  of  the  former  and  52  of  the  latter  variety. 
It  is  doubtful  whether  the  conditions  are  pathologically  the  same:  in 
the  cases  which  develop  during  pregnancy  the  glandular  elements 
are  markedly  increased,  whereas  in  the  virginal  form  it  is  a  pure 
fibromatous  over-growth,  the  undeveloped  glandular  elements  being 
practically  unchanged.  This  difference  may  be  due  merely  to  the 
undeveloped  condition  of  the  virgin  breast. 

Both  breasts  are  enlarged  in  almost  all  cases  (62  out  of  70  cases 
collected  by  Albert),  and  they  may  reach  an  immense  size.  In  Durs- 
ton's  historic  case,  recorded  in  1669,  the  weight  of  one  breast,  removed 
postmortem,  was  64  pounds.  Seldom,  however,  does  the  weight 
exceed  8  to  12  pounds.  There  are  no  symptoms  other  than  dis- 
comfort from  the  size  and  weight,  but  the  breasts  may  increase 
and  decrease  slightly  in  size  from  time  to  time.  The  form  which 
arises  during  pregnancy  sometimes  subsides  spontaneously  when  the 
pregnancy  and  lactation  are  ended;  but  the  virginal  form  progres- 
sively increases.  The  growth  is  slow,  and  the  disease  extends  over 
many  years.  Ver\'  rapid  enlargement  of  one  breast  alone,  though 
it  bear  the  character  of  a  simple  hypertrophy,  always  should  rouse 
suspicion  of  malignancy,  especially  sarcoma. 

Treatment. — Treatment  of  the  condition  which  arises  during  preg- 
nancy always  should  be  palliative;  this  consists  in  the  recumbent 
position,  with  elevation  and  compression  of  the  breasts;  the  use  of 
sorbefacient  ointments  locally;  the  internal  administration  of  potas- 
sium iodide  or  thyroid  extract ;  repeated  catharsis,  and  a  dry  diet.  If 
no  improvement  is  noted  after  pregnancy  has  terminated,  and  in  the 
virginal  cases  as  soon  as  the  diagnosis  is  assured,  one  of  the  breasts 
should  be  amputated.    In  a  few  cases  the  remaining  breast  has  then 


( '  VST  A  DENOMA  TOSIS  71)7 

somewhat  (l('(Tcas(>(l   in   size.      If   it   docs  not,  it  should  he   removed 
sul)se((ueiitl\'. 

Cystadenomatosis  or  Abnormal  Involution  of  the  Breast.  In  \SS'A 
Uechis  (k'scrihed  in  detail  a  "cystic  disease  of  the  breast,"  wjiich 
he  had  studied  first  over  twenty  years  before,  and  which  had  been 
recognized  by  F.  Kcinig  (1<S75),  by  Brodie  (184G),  and  by  Sir  Astley 
Cooper  ( 1S29).  In  more  recent  times  it  has  l)een  studied  by  Schimmel- 
i)usch  (l.SOO),  who  named  it  cysiadenoma;  by  Konig  (1893),  who 
called  it  mast  His  chronica  cystica;  by  J.  C.  Warren  (1905),  for  whom 
it  is  an  abnormal  involution  of  the  breast;  and  by  Bloodgood  (1900). 
who  called  it  senile  parenchymatous  hypertrophy.  These  are  only  a 
few  of  the  names  by  which  it  is  known.  It  matters  little  by  what 
name  it  is  called,  so  long  as  people  understand  what  is  referred  to; 
and  I  ha\e  not  had  the  temerity  to  select  a  new  name  for  it,  but  have 
followed  Warren,  who  restored  it  to  the  position  in  the  nosology 
of  breast  lesions  to  which  it  was  originally  assigned  by  Sir  Astley 
Cooper:  a  pathological  change  similar  in  nature  to  that  of  diffuse 
virginal  "hypertrophy,"  though  characterized  by  epithelial  (cystic) 
growth,  where  the  latter  is  characterized  by  fibrous. 

The  disease  is  very  frequent,  but  may  exist  for  years  without 
producing  symptoms  Though  seen  oftenest  in  women  from  thirty 
to  fifty  years  of  age,  this  is  no  proof  that  it  has  not  had  an  obscure 
beginning  at  a  much  earlier  age.-  Occasionally  it  comes  under  obser- 
vation shortly  after  puberty,  when  the  mammary  glands  begin  to 
develop;  but  is  much  more  frequently  seen  when  their  functional 
activity  is  drawing  to  a  close.  It  is  rare  after  the  menopause.  In 
most  cases  both  breasts  are  diseased,  though  only  one  may  produce 
symptoms.  The  disease  appears  to  be  as  common  in  the  unmarried 
and  in  those  who  have  borne  no  children  as  in  those  in  whom  the 
mammary  glands  have  been  functionally  active. 

Symptoms  and  Clinical  Course. — The  woman  consults  a  physician 
usually  because  she  has  an  uncomfortable  feeling  in  the  breast,  and 
perhaps  because  she  has  noticed  that  it  has  grown  larger,  or  because 
by  accident  she  has  felt  a  lump  in  it.  On  examination  the  breast 
generally  is  found  enlarged,  but  not  unduly  pendulous.  No  lump  or 
tumor  is  visible.  If  the  gland  is  picked  up  in  the  thumb  and  fingers, 
it  may  seem  that  there  is  a  considerable  tumor  in  it,  but  if  the  hand 
presses  the  gland  fiat  against  the  chest  it  is  evident  that  there  is  no 
tumor  at  all.  There  should  now  be  undertaken  what  Astley  Cooper 
calls  a  very  careful  and  nice  manipular  examination.  What  is  detected 
is  very  characteristic:  seemingly  each  individual  lobule  can  be  felt 
distinctly,  enlarged  and  hardened,  and  moving  freely  upon  the  other 
lobules.  The  breast  feels  as  if  it  were  full  of  lead  shot,  varying  in 
size  from  pin-head  to  grape-size.  Early  in  the  disease  no  large  masses 
are  felt.  These  little,  hard  masses  are  mostly  in  the  centre  of  the 
gland,  beneath  the  nipple  and  areola.  Pressure  on  the  breast  causes 
no  pain,  but  an  occasional  shooting  pain  occurs.  The  overlying 
skin  is  normal.    There  is  no  discharge  from  the  nipple.    The  axillary 


708  SURGERY  OF  THE  BREAST 

nodes  are  not  palpable.  If  now  the  other  breast  be  examined,  almost 
invariably  a  similar  condition,  perhaps  not  so  pronounced,  will  be 
found  in  it. 

If  such  a  breast  is  amputated,  it  is  found  that  the  shot-like  particles 
which  felt  so  hard,  and  which  were  distributed  through  all  parts  of 
the  gland,  are  not  solid  at  all,  as  one  might  imagine;  they  are  minute 
cysts,  tensely  filled  with  clear  or  slightly  yellow  or  even  brownish 
fluid.  The  cyst  walls  are  smooth;  there  are  no  intracystic  growths. 
Microscopical  examination  shows  that  the  cysts  are  lined  with  gland- 
ular epithelium,  which  shows  little  if  any  tendency  to  proliferation 
beyond  the  capacity  of  the  basement  membrane ;  seldom  in  any  place 
is  there  more  than  one  row  of  cells  on  the  basement  membrane,  and 
never  is  there  any  papillomatous  out-gro^^i;h  into  the  cavity  of  the 
cyst.  The  stroma  of  the  breast  is  a  dense  white  mass  of  fibrous 
tissue,  and  there  is  no  single  area  in  the  entire  breast  which  can  be 
said  to  be  free  of  disease.  The  change  is  not  one  of  tumor  formation, 
but  a  general  blastomatoid  over-growth. 

If  no  treatment  is  instituted  the  disease  may  progress;  or  after  a 
few  years,  a  secondary  atrophy  may  set  in,  the  breast  decreasing  in 
size,  all  symptoms  subsiding,  and  the  patient  remaining  well.  This, 
however,  is  rare;  in  most  cases  the  disease  is  progressive.  In  one 
portion  of  the  breast  a  larger,  more  clearly  outlined  mass  may  be  felt, 
and  sometimes  there  are  two  or  tliree  such  masses.  They  may  be 
visible  as  rounded  projections  beneath  the  skin.  When  very  large 
they  may  give  a  sense  of  fluctuation.  They  are  cysts;  and  have 
formed  by  the  gradual  distention  of  one  or  more  of  the  small  cysts 
which  have  been  present  for  years.  In  other  parts  of  the  breast  these 
small  cysts  may  still  be  felt  on  "nice  manipular  examination."  At 
this  latter  stage  of  the  disease,  there  sometimes  is  a  glairy  or  clear 
yellowish  discharge  from  the  nipple;  pressure  on  the  cysts  may  cause 
this  fluid  to  appear.  The  cysts  may  oscillate  in  size  from  month  to 
month,  and  at  times  the  axillary  lymph  nodes  may  become  palpable, 
and  again  this  swelling  may  subside.  Pathological  examination  at 
this  stage  may  show  the  cysts  still  simple  in  nature,  with  smooth 
lining  wall,  but  in  the  vast  majority  of  cases  the  cysts,  at  least  the 
larger  ones,  contain  intracystic  papillomatous  out-growths. 

If  still  no  treatment  is  instituted,  some  of  the  clinical  characteristics 
of  malignancy  may  be  noted.  The  nipple  may  seem  retracted  into 
the  gland,  but  usually  can  be  drawn  out  easily,  the  skin  may  become 
adherent,  not  by  cellular  infiltration,  but  by  condensation  of  the 
intervening  tissues ;  and  at  last  one  of  the  cysts  may  grow  so  large  as 
to  cause  pressure  necrosis  of  the  overlying  skin.  The  contents  of  the 
cyst  will  then  be  discharged,  and  the  cyst,  if  it  contains  no  papillo- 
matous out-growths,  may  collapse,  and  in  rare  cases  healing  may 
occur.  If  the  cyst  contains  papillomatous  out-growths,  these  may 
protrude  tlirough  the  opening  formed  in  the  skin  by  sloughing, 
and  a  fungus  growth  will  develop  which  it  may  be  very  difficult  to 
distinguish  from  a  malignant  tumor.    At  the  present  day,  however. 


C  VST  A  DEXOMA  TOSI.S  709 

it  is  almost  an  unknown  tiling  for  the  disease  to  he  allowed  to 
reach  this  advanced  sta<;e,  as  the  breast  is  removed  at  an  earlier 
period. 

Another,  and  probably  more  frequent  contingency  may  arise. 
Instead  of  the  disease  taking  on  a  cystic  type  of  development,  which 
usually  is  quite  benign,  it  may  undergo  an  adenomatous  transforma- 
tion, in-growths  occurring  from  the  ducts  or  cyst  walls  into  the  sur- 
rountling  stroma;  and  in  about  10  or  15  i^cr  cent,  of  cases  the  disease 
terminates  as  a  carcinoma  (Speese,  1910).  It  is  on  this  account  that 
its  early  recognition  and  proper  treatment  are  so  important. 

Diagnosis. — In  its  onset  this  affection  of  the  })reasts  resembles 
chronic  mastitis,  and  by  many  it  is  still  considered  infectious  in  origin 
There  seems  to  be  no  doubt  that  previous  attacks  of  mastitis  pre- 
dispose the  patient  to  the  development  of  this  disease.  And  in  some 
cases  it  is  nearly  impossible  to  say  ofi'-hand  that  this  is  a  case  of 
diffuse  chronic  mastitis  and  not  one  of  "abnormal  involution,"  or 
vice  versa.  I  have  preferred  to  discuss  the  disease  entirely  in  one  place, 
and  for  this  reason  have  described  only  a  localized  and  not  a  diffuse 
form  of  clironic  mastitis  (p.  702).  From  cystadenoma  of  the  breast 
(p.  712)  its  differentiation  also  is  difficult  especially  in  the  later  stages; 
but  as  a  rule  even  in  such  cases  the  dift'use  nature  of  the  process  is 
evident.  While  the  cystadenoma  is  at  first  a  localized  growth,  it 
increases  in  size  much  more  rapidly  than  does  the  breast  which  is 
the  seat  of  diffuse  cystadenomatosis;  and  only  after  the  latter  con- 
dition has  existed  for  many  years  will  cysts  be  present  commensurate 
in  size  with  those  of  a  cystadenoma  of  some  months'  duration.  As 
in  this  stage  the  treatment  for  both  affections  is  the  same  (amputation 
of  the  breast),  the  distinction  is  not  of  great  importance. 

Treatment. — 1.  If  the  woman  is  young  (under  thirty-eight  years),  the 
cystadenomatoid  change  recently  discovered  and  presumably  of  slow 
growth,  she  should  be  kept  under  strict  surgical  observation,  a  careful 
manipular  examination  of  the  breasts  being  made  at  monthly  inter- 
vals. Meantime  such  general  hygienic  measures,  changes  in  clothing 
and  habits  of  life,  and  attention  to  menstrual  derangements  should 
be  enforced  as  seem  indicated.  Local  treatment  has  little  value,  but 
such  as  was  recommended  for  chronic  mastitis  (p.  703)  is  at  least  harm- 
less. If  the  condition  remains  stationary,  or,  still  better,  if  it  seems 
to  subside,  well  and  good;  no  operation  is  required.  If  it  continues 
to  progress,  the  breast  (often  both  of  them)  must  be  operated  on. 
The  operation  may  be  begun  by  an  exploratory  incision,  as  in  the 
method  of  "plastic  resection"  of  the  breast  (p.  711);  when  the  gland 
tissue  is  exposed  and  incised,  the  subsequent  course  of  the  operation 
wdll  depend  on  what  is  found.  If  only  one  or  two  fairly  large  cysts 
are  found,  and  no  suspicion  of  malignancy  exists,  it  is  sufficient  to 
excise  the  cysts  and  leave  the  greater  portion  of  the  gland  intact. 
If  a  number  of  cysts  are  present  the  entire  breast  should  be  ampu- 
tated, as  described  below.  If  any  suspicion  of  malignancy  exists, 
the  axilla  should  be  exposed,  cleared,  and  its  contents  should  be 


710  SURGERY  OF  THE  BREAST 

removed  in  one  mass  with  pectoral  muscles,  mammary,  gland,  and 
overlying  skin. 

2.  If  the  woman  is  past  the  age  of  greatest  functional  activity  of 
the  mammary  glands  (and  this  age  varies  in  individuals  as  in  different 
races),  it  is  better  to  remove  the  breasts  at  once,  since  the  probability 
of  actual  or  subsequent  malignant  change  is  much  greater  at  this 
period  of  life. 

Whenever  the  breast  is  removed  it  should  be  most  scrupulously' 
examined  macroscopically;  any  and  every  area  suggesting  malignancy 
should  then  be  studied  microscopically  by  a  competent  pathologist. 
Such  areas  are  intracystic  papillomatous  growths,  or  areas  of  greater 
density  or  of  ulceration  in  the  cyst  walls.  Only  one  very  minute 
area  such  as  this  maj^  be  present  in  the  entire  gland,  and  it  is  very 
easily  overlooked.  The  question  of  malignancy  should  be  decided, 
as  it  is  vital  for  prognosis  and  the  patient's  peace  of  mind. 

I  place  no  reliance  at  all  on  diagnoses  made  during  the  progress 
of  the  operation  from  microscopical  study  of  frozen  sections;  yet 
I  know  that  Rodman  and  other  experienced  surgeons  still  deem  this 
method  of  value.  The  macroscopical  appearance  of  the  breast  should 
be  a  better  guide  to  the  surgeon,  and  my  own  judgment  agrees  with 
that  of  Bloodgood  and  others,  that  no  surgeon  should  be  satisfied 
to  operate  on  these  borderline  cases  unless  he  has  the  skill  and 
knowledge  to  differentiate  clinically  at  the  time  of  operation  between 
growths  certainly  benign  and  those  possibly  malignant. 

Amputation  of  the  Breast. — An  incision  is  made  in  the  submammary 
crease,  from  the  anterior  axillary  fold  inward  to  the  parasternal 
line.  The  lower  edge  of  the  pectoralis  major  is  exposed,  and  the 
mammary  gland  thrown  upward  on  the  patient's  chest.  The  gland 
can  then  be  explored  from  the  posterior  surface.  If  amputation, 
instead  of  plastic  resection  or  radical  ablation,  is  determined  upon, 
a  curved  incision  is  then  made  above  the  breast,  joining  the  ends  of 
that  already  made.  The  flaps  are  dissected  up  sufficiently  to  ensure 
complete  removal  of  all  glandular  tissue.  The  wide  area  over  which 
this  iRSiy  be  spread  should  be  remembered  (p.  721).  The  surface  of 
the  pectoralis  major  is  then  exposed  above  and  the  fascia  is  dissected 
from  it  downward.  Bleeding  points,  chiefly  branches  of  the  inter- 
costals,  are  clamped  as  severed.  The  superficial  fibres  of  the  muscle 
are  removed,  and  the  mammary  gland  is  excised  in  one  piece  with  the 
nipple  and  overlying  skin,  the  surrounding  fat,  and  the  pectoral  fascia. 
Hemorrhage  being  controlled  by  ligature,  the  wound  is  closed  with 
interrupted  sutures,  and  provision  is  made  for  drainage  for  a  few  days. 

Benign  Tumors. — Benign  tumors  of  the  breast  are  rare.  They  occur 
mostly  in  young  women,  from  fifteen  to  thirty  years  of  age,  and  in 
almost  all  cases  are  fibro-epithelial  in  type  (Ribbert,  1901).  They 
are  conveniently  divided,  as  is  done  by  Warren,  into  two  subdivisions: 
(1)  Those  in  which  the  fibrous  element  predominates  fihro-adenoma; 
and  (2)  those  in  which  the  epithelial  element  is  conspicuous — cyst- 
adenoma. 


A7 HRO-A DENOMA  TOVS  TUMORS  7 1 1 

1 .  Fibro- adenomatous  Tumors.  -These  arc  particularly  character- 
ized by  iic()i)lastic  <fr()\vth  of  the  stroma  which  surrounds  the  gland 
ducts;  hence  they  are  all  described  as  jwriduvtal  tionorff.  If  the  tumor 
is  mostly  pure  fibrous  tissue,  like  that  found  in  the  virgin  breast, 
it  is  called  a  periditrtal  fibroma;  and  the  fibromatous  change  may  be 
either  intra-canal'intUir  in  type,  or  prrianmllculur:  in  the  former 
case  the  fibromatous  tissue  comi)resses  and  distorts  the  ducts,  so  that 
these  api)ear  as  curved  slits  or  chinks  in  the  microscopical  field; 
while  in  the  peri-canalicular  form  the  normal  appearance  of  the 
ducts  is  largely  ])reserved.  In  most  cases,  instead  of  a  pure  fibro- 
matous tumor,  there  is  myxomatous  degeneration  of  the  fibroma,  and 
the  growth  is  known  as  a  periductal  viyxoDiu;  this  is  the  form  most 
frequently  encountered,  though  prol)ably  at  an  earlier  stage  the 
tumor  was  more  purely  fibromatous.  In  rare  cases,  the  stroma  of  the 
tumor  instead  of  being  fibromatous  or  myxomatous  is  sarcomatous, 
and  the  growth  is  called  periductal  sarcoma. 

Symptoms  and  Clinical  Course. — Usually  occurring  in  young 
unmarried  women,  these  growths  well  deserve  the  name  "chronic 
mammary  tumor"  bestowed  upon  them  by  Sir  Astley  Cooper.  They 
present  few^  symptom's  other  than  the  presence  of  a  "lump  in  the 
breast,"  which  usually  is  discovered  accidentally,  and  may  be  attril)- 
uted  to  injury.  When  of  long  duration  a  visible  swelling  may  exist. 
This  swelling  or  lump  is  in  the  central  portion  of  the  gland,  but  not 
close  to  tlie  nipple.  It  feels  hard,  is  well  defined  from  the  rest  of  the 
gland,  is  not  tender,  and  seldom  is  movable  except  in  one  mass  with 
the  breast.  Palpation  of  the  breast  with  the  flat  hand,  pressing  it 
against  the  chest,  demonstrates  the  presence  of  an  actual  tumor;  the 
lump  does  not  vanish  as  does  that  due  to  chronic  mastitis,  when  this 
mana?uvre  is  adopted.  The  overlying  skin  is  not  affected,  nor  are  the 
axillary  uodes  enlarged.  The  tumor  grows  very  slowly,  and  ma}' 
remain  for  years  in  much  the  same  condition.  Occasionally,  however, 
rapid  growth  occurs;  this,  of  course,  is  a  bad  omen.  But  in  most 
cases  the  prognosis  is  absolutely  good. 

Treatment. — The  tumor  should  be  removed.  It  is  encapsulated, 
and  by  exposing  the  posterior  surface  of  the  mammary  gland,  as 
described  below,  the  growth  can  be  enucleated,  the  breast  replaced, 
and  no  visible  scar  wdll  remain.  This  method  of  plastic  resection  of 
the  breast,  introduced  in  1882  by  T.  Gaillard  Thomas,  has  been  re- 
vivified by  J.  Collins  Warren.  It  is  thus  performed:  An  incision 
is  made  from  the  anterior  axillary  fold  inward  in  the  submammary 
crease,  as  far  as  the  inner  lower  quadrant  of  the  breast.  This  incision 
is  deepened  to  expose  the  pfictoralis  major,  and  the  mammary  gland 
is  dissected  from  its  surface  and  is  thrown  upward  on  the  patient's 
chest.  As  the  main  blood-supply  of  the  gland  enters  it  from  its 
superficial  surface,  near  its  upper  border,  no  fear  of  sloughing  need 
be  felt.  The  posterior  surface  of  the  gland  being  thus  brought  to 
vieW',  the  region  of  the  tumor  is  exposed  by  an  incision  radiating  from 
the  centre;  the  tumor  is  enucleated,  and  the  cavity  is  obliterated  by 


712  SURGERY  OF   THE  BREAST 

catgut  sutures,  thus  restoring  the  contour  of  tlie  breast.  This  is 
then  replaced  on  the  pectoral  muscle,  and  the  deep  layer  of  the 
superficial  fascia  carefully  sutured,  so  as  to  retain  the  breast  in  place; 
and  tlic  >kin  i>  clo-cd  w  ith  ])ruvision  for  drainage. 

2.  Cystadenomatous  Tumors. — These  seem  to  represent  a  later 
development  of  the  fibro-adenomatous  tumors  just  described;  and 
as  nearly  all  growths  in  the  breast  at  the  present  day  are  removed 
soon  after  their  presence  is  discovered,  it  results  that  cystadenomatous 
tumors  are  much  more  rare  now  than  fifty  or  one  hundred  years  ago. 
At  that  time  the  curious  combination  of  fibrous  and  epithelial  pro- 
liferation, resulting  in  solid  (perhaps  sarcomatous)  tumors  filled 
with  cysts,  was  productive  of  great  confusion  as  regards  nomenclature. 
This  class  of  tumor  was  described  by  Astley  Cooper  as  hydatid  disease 
of  the  breast;  Brodie  called  it  sero-cystic  sarcoma;  Paget  named  them 
proliferous  mammary  cysts;  and  Johannes  Miiller  used-  the  term 
cysto-sarcoma  phyllodes,  both  the  latter  observers  laying  special  stress 
on  the  occurrence  of  intracystic  papillary  out-gro^\i:hs  To  the  present 
day  the  French  call  it  adeno-sarcoma. 

The  grovslh  consists,  in  fact,  of  a  cystic  tumor,  with  a  more  or 
less  abundant  fibrous  stroma — a  fibrocysiadenoma.  The  cysts  are 
of  various  sizes,  usually  some  of  them  quite  large.  Their  lining 
membrane  may  be  quite  smooth,  as  if  from  pressure  atrophy.  Almost 
invariably  from  one  or  more  areas  of  the  cyst  wall,  papillomatous 
growths  project — papillary  cystadenoma.  These  intracystic  growths 
have  a  solid  core  of  fibrous  tissue,  and  they  may  completely  fill  the 
cyst  and  even  cause  its  distention.  It  seems  as  if  the  proliferation  of 
the  stroma  had  converted  the  semi-circular  chinks  or  slits  of  the 
intracanalicular  fibroma  into  actual  cysts  formed  by  the  pressure  of 
papillary  out -growths  into  the  duct  lumen.  This  impression  is  con- 
firmed by  the  fact  that  the  papillomas  are  covered  with  cells  which 
present  the  characteristics  of  ductal  rather  than  of  acinal  epithelium. 
The  small  amount  of  fluid  which  the  cysts  contain  may  be  colorless, 
slightly  tinged  with  yellow  or  green,  but  usually  is  brownish  or  hem- 
orrhagic in  nature. 

Symptoms  and  Clinical  Course. — These  tumors  occur  in  older  women 
than  do  the  fibro-adenomatous  gro"uths.  The  average  age  in  Warren's 
patients  was  fifty-two  years.  Indeed,  in  most  cases  where  cysts 
are  found  in  the  mammary  gland  it  is  an  indication  that  this  organ 
has  reached  its  full  maturity  before  the  tumor  began  to  grow.  Cyst- 
adenoma  grows  more  rapidly  than  the  solid  benign  tumors,  and  if 
not  removed,  may  reach  a  large  size.  The  growth  is  situated  in  the 
central  part  of  the  breast,  beneath  the  nipple  or  areola,  and  at  first 
presents  much  the  same  features  as  the  fibro-adenoma.  In  the  course 
of  a  few  years,  however,  the  presence  of  cj^sts  usually  may  be  sus- 
pected from  the  lobulated  nature  of  the  tumor,  and  sometimes  from 
distinct  fluctuation.  But  the  latter  rarely  occurs,  since  the  cysts 
are  apt  to  be  filled  with  the  papillary  out-growths,  which  give  them 
a  solid  feel.     The  overlying  skin  is  not  altered,  the  axillary  nodes 


SARCOMA  713 

arc  not  enlar<;e(l,  and  seldom  is  the  f^eiu'ral  health  aH'eeted.  Very 
often  there  is  a  hloody  (hseharj^e  from  the  nipple.  In  \ery  advanced 
cases  the  skin  overix  in<f  one  of  the  cysts  may  become  thinned,  and  a 
seinitranslucent  appearance  may  be  present.  The  l)reast  may  be 
covered  with  a  network  of  distended  veins.  Finally,  as  in  the  most 
advanced  staji;es  of  cystadenomatosis  (p.  707)  i)erforation  of  the  skin 
may  occur,  with  the  protrusion  of  the  intracystic  papillomas  as  a 
fungus  growth,  .it  any  .stage  of  the  disease  maliynant  changes  may 
occur.  These  may  develop  in  the  epithelial  elements  (carcinoma), 
or  rarely  in  the  stroma  (sarcoma.) 

Diagnosis. — The  diagnosis  must  be  made  from  fibro-adenoma, 
and  from  cystadenomatosis.  From  the  former,  cystadenoma  usually 
may  be  distinguished  by  the  greater  age  of  the  patient,  by  the  less 
dense  feel  and  less  definite  outline  which  the  growth  presents;  as 
well  as  by^  its  more  rapid  enlargement  and  its  eventually  cystic  char- 
acter. From  cystadenomatosis  of  the  breast  the  distinction  is  difficult 
only  in  the  later  stages,  when  the  primarily  local  tumor  (cystadenoma) 
has  grown  so  large  as  to  occupy  nearly  the  entire  area  of  the  mammary 
gland. 

Treatment. — Ablation  of  the  breast,  pectoral  muscles,  and  axillary 
lymphatics,  as  for  carcinoma,  is  the  safest  treatment  in  patients 
over  thirty-eight  or  forty  years  of  age.  In  younger  patients,  in 
whom  malignant  changes  are  less  likely,  amputation  of  the  breast 
is  sufficient. 

Other  benign  tumors  occur  in  the  breast,  but  are  extremely  rare, 
and  present  only  pathological  interest.  A  pure  adenoma  has  been 
described  by  S.  W.  Gross  (1880)  and  by  Rodman:  it  is  a  soft,  suc- 
culent, nodular,  rather  rapidly  growing  tumor,  not  very  well  encap- 
sulated, and  affecting  young  women.  Lipoma  may  occur  in  the 
interlobular  tissues  of  the  mammary  gland,  in  the  subcutaneous  fat 
overlj'ing  it,  or  in  the  submammary  tissues.  Cases  of  angeioma 
and  endothelioma  have  also  been  recorded.  Enchondroma  is  another 
rare  growth,  de\eloping  here,  as  in  the  salivary  glands,  in  the  form 
of  a  "mixed  tumor,"  with  areas  of  cartilage  and  calcareous  matter. 
The  diagnosis  of  these  rare  growths  sometimes  is  not  made  until 
after  removal,  which  is  the  proper  treatmejit. 

Malignant  Tumors  of  the  Breast. — The  general  character  of  malignant 
as  distinguished  from  l)enign  tumors  was  indicated  in  Chapter  IV, 
and  it  is  not  necessary  to  repeat  tliis  discussion  here.  It  is  enough 
to  say  that  over  70  per  cent,  of  tumors  of  the  breast  are  malignant, 
and  that  in  women  approaching  or  past  the  menopause  every  tumor 
should  be  regarded  as  malignant,  and  should  be  treated  accordingly. 

Sarcoma. — Sarcoma  is  very  rare.  It  occurs  in  less  than  3  per  cent. 
of  cases  of  mammary  neoplasm.  Reference  was  made  at  (p.  711) 
to  a  form  of  periductal  sarcoma,  which  is  classed  among  the  benign 
tumors.  This  forms  about  80  per  cent,  of  the  cases  of  sarcoma  of  the 
breast  on  record,  a  fact  which  emphasizes  the  exceeding  rarity  of 
true  mammary  sarcoma.   This  truly  malignant  form  of  sarcoma  which 


714 


SURGERY  OF  THE  BREAST 


forms  only  20  per  cent,  of  the  recorded  cases  of  mammary  sarcoma, 
is  of  the  spindle-  or  round-celled  type,  and  epithelial  proliferation  is 
scanty  or  absent.  The  tumor  affects  women  at  any  age,  probably 
most  often  those  between  forty  and  fifty  years.  At  first  it  is  a  well 
defined,  small,  indolent  mass,  which  may  cause  no  symptoms  for 
years.  Eventually,  however,  rapid  growth  sets  in,  the  timior  breaks 
through  its  imperfect  capsule,  infiltrates  the  mammary  gland,  causes 
distention,  redness,  and  sloughing  of  the  overlying  skin,  and  in  a  few 
months  or  even  weeks  there  is  a  protruding,  fungus,  bleeding  mass 
(fungus  hematodes).  The  diagnosis  is  difficult  in  the  early  stages; 
when  seen  at  this  time  the  growth  may  be  mistaken  for  a  benign 
tumor.  Treatment  consists  in  early  amputation  of  the  breast;  the 
axillary  lymphatics  very  rarely  are  involved,  but  in  patients  past 
thirty-eight  or  forty  years  it  is  a  wise  i)recaution  to  substitute  ablation 
for  amputation,  as  in  cases  of  carcinoma. 

Carcinoma. — Carcinoma    is    the    most    frequent    affection    of    the 
breast.     Only  about  1   per  cent,  of  cases  occur  in  the  male  breast 

(Fig.  789).  Most  tumors  of 
the  breast  in  women  over  forty 
years  of  age  are  carcinomatous, 
but  the  disease  is  not  at  all 
infrequent  at  an  earlier  age. 
The  older  the  patient,  the 
more  apt  is  a  tumor  to  be 
carcinomatous.  The  left  and 
right  breasts  are  affected  with 
al)out  equal  frequency.  Very 
rarely  are  both  breasts  simulta- 
neously attacked  (in  about  1  per 
cent,  of  cases),  l)ut  the  disease 
may  spread  from  one  gland  to 
the  other  through  the  lymph- 
atics (Fig.  740).  Heredity  has 
little  influence  in  the  clinical 
etiology  of  the  affection,  nor 
has  race.  It  is  more  frequent 
in  married  than  unmarried 
women,  particularly  in  those 
The  influence  of  direct  trauma 


'.).  -Scii'i  licus  cari'iiiiiiiKi  (if  uiai 
breast,  am;  fifty-iiiiit'  years;  duration  three 
years;  rapid  growth  for  one  year.  Axillary 
nodes  palpable.  (Dr.  J.  P.  Hutchinson's 
case.)     Pennsylvania  Hospital. 


who  have  borne  and  suckled  children, 
seldom  is  noted  (Plate  V). 

Pathology. — A  tumor  of  the  mammary  gland  may  begin  as  a  car- 
cinoma, or  carcinoma  may  develop  in  a  previously  existing  benign 
tumor.  The  latter  is  much  the  rarer;  it  oftenest  succeeds  the  change 
described  as  abnormal  involution  of  the  breast  (p.  707)  and  assumes 
the  type  of  adeno-carcinoma,  or  "duct  cancer"  (p.  125).  In 
this  form  the  tumor  lies  near  or  beneath  the  nipple,  which  is  not 
retracted;  the  growth  is  soft,  shows  little  tendency  to  infiltrate,  but 
early  breaks  through  the  skin,  and  appears  as  an  ulcer  without  the 


PLA'FE  V 


Scirrhous  Carcinoma  of  Breast. 

Specimen  (half  natural  size)  from  excision  of  right  breast  for  carcinoma.  Aged  45  years;  duration 
2 5  years,  ulcerated  6  months.  Tumor  developed  a  few  months  after  direct  trauma.  Note  the  "rose 
ulcer"  in  the  uiipor  outer  quadrant,  measuring  3x2  inches  and  covered  with  adherent  gray-green  slough; 
beneath  this  was  a  hard  tumor  the  size  of  a  goose  egg  (Plate  VI),  not  attached  to  chest  wall.  Visible 
mass  in  axilla.   Tumor,  i^ectoral  muscles,  and  axillary  structures  removed  in  one  mass.    Episcopal  Hospital. 


,SClliUlli>VS   CARCINOMA 


715 


liard  and  tliickt'iu'd  inaririns  so  characteristic  of  the  commoner  types 
of  carcinoma,  and  ha\  in<,'  its  surface  not  depressed  but  rather  ele- 
vated above  the  surrounding^  skin.  Rarely  does  this  growth  long  pre- 
serve the  relatively  benign  character  of  an  adeno-carcinoma;  it  soon 
lirt)liferates  in  an  atypical  manner  like  the  solid-celled  carcinoma. 
The  latter,  which  is  the  usual  form  of  carcinoma  seen  in  the  breast, 
arises  in  an  atypical  proliferation  of  the  ei)ithclial  cells  lining  the 
acini  of  the  gland,  and  thus  is  distinguished  from  the  rarer  and  less 
malignant  duct-cancer  by  the  term  acinous  carcinoma. 


Fig  740.— Carcinoma  simplex  of  both  breasts,  age  sixty-six  years.  Growth  in  left 
breast  for  five  years,  ulcerated  five  months;  large  sloughmg  ulcer;  axillary  nodes  palpable. 
Growth  in  right  breast  for  two  years:  skin  red  and  adherent;  nippe  retracted ;  axillary 
nodes  palpable.  Palliative  amputation  of  both  breasts  in  October,  1909  with  prolonged 
after-treatment  by  x-rays.  (Dr.  Thos.  S.  Stewart.)  In  September  1911,  a  metastatic 
growth  appeared  in  right  thigh.  In  August,  1913,  mediastinal  and  pulmonary  metastases 
but  no  local  recurrence.  In  January,  1914,  feeble,  but  little  discomfort.  Episcopal 
Hospital. 

The  microscopical  features  of  adeno-carcinoma  and  solid-celled 
carcinoma  were  considered  at  (p.  125).  Clinically,  the  usual 
type  of  mammary  carcinoma,  that  classed  as  solid-celled,  is  en- 
countered in  tlu-ee  varieties  dependent  upon  the  relative  amount 
of  stroma  present:  Scirrhous  Carcinoma,  in  which  stroma  is  very 
abundant  and  cellular  elements  scanty;  Carcinoma  Simplex,  in  which 
stroma  and  epithelial  elements  exist  in  equal  amount;  and  Medullary 
Carcinoma,  in  which  the  epithelial  elements  are  very  abundant  and 
the  stroma  is  scanty.  The  clinical  features  of  these  three  forms  may 
now  be  briefly  considered. 

Scirrhous  Carcinoma,  or  simply  Scirrhus,  is  the  most  frequent 
form  of  mammary  cancer.  Owing  to  the  abundance  of  the  stroma 
the  tumor  is  quite  hard;  it  seems  as  if  the  surrounding  tissues  were 
endeavoring  to  stifle  the  growth  of  the  epithelial  elements.  On 
section  the  tumor  is  found  to  be  absolutely  continuous  with  the 
surrounding  tissues;  there  is  not  the  slightest  indication  of  a  capsule; 
it  is  impossible  to  remove  the  tumor  from  the  gland.     It  is  hard. 


710 


SURGERY  OF  THE  BREAST 


and  creaks  when  cut  by  the  knife.  Usually  both  the  cut  surfaces  are 
found  to  be  concave;  it  is  as  if  the  tumor  was  too  small  for  the  tissues 
in  which  it  grew,  and  tended  to  contract  further  at  the  first  opportu- 
nity. The  surface  of  the  section  often  has  been  likened  to  that  of  an 
unripe  pear:  it  is  pale  and  shiny,  grayish  white  at  first,  but  becomes 
pinkish  on  exposure  to  the  air.  Usually  there  are  yellow  dots  scat- 
tered over  the  surface  of  the  tumor;  these  are  either  spots  of  fatty 
degeneration,  or  areas  of  fatty  tissues  not  yet  strangulated  by  the 
fibrous  stroma.  On  scraping  the  section  with  the  knife,  "cancer- 
juice"  is  produced;  but  this  is  no  longer  regarded  as  particularly 
characteristic  of  carcinoma. 

Symptoms  and  Clinical  Course. — The  patient  finds  a  lump  in  her 
breast,  but  rarely  are  there  any  subjective  symptoms.  There  may 
be  occasional  lancinating  pains,  but  the  tumor  is  not  tender,  a  fact 
which  distinguishes  it  from  all  inflammatory  swellings.     This  lump 

in  most  cases  lies  in  the  per- 
iphery of  the  mammary  gland, 
not  near  the  nipple;  and  is 
found  oftenest  in  the  upper 
outer  quadrant.  It  is  hard, 
but  not  definitely  outlined, 
when  felt  between  the  thumb 
and  fingers;  and  it  is  still  pal- 
pable as  a  dense  nodule  when 
the  breast  is  pressed  by  the 
palm  of  the  hand  flat  against 
the  patient's  chest.  This  dis- 
tinguishes it  from  non-neoplas- 
tic  thickenings  of  the  mammary 
gland.  Owing  to  the  abundance 
of  the  fibrous  stroma  and  its 
tendency  to  contract,  the  size 
of  the  breast  usually  is  dimin- 
ished in  cases  of  scirrhus;  when 
this  contraction  is  extreme,  the  condition  is  named  atrophic  or 
withering  scirrhus  (Fig.  741).  An  early  and  valuable  sign  due  to 
this  contracting  tendency  has  been  pointed  out  by  Halsted:  this 
is  limitatio7i  of  the  excursions  on  the  chest  wall  of  the  affected  mamma 
as  compared  with  the  normal  gland.  If  the  breast  is  pulled  from  side 
to  side,  and  up  and  down,  even  in  the  case  of  a  small,  deeply  seated, 
and  almost  impalpable  nodule,  it  will  be  found  that  the  excursions 
of  the  affected  breast  are  diminished,  especially  in  a  direction  away 
from  the  axilla.  The  cancer  cells  extend  along  planes  of  fascia  in  all 
directions,  and  the  abundant  fibrous  stroma  follows  them  up,  as  if 
in  the  endeavor  to  strangle  them  by  its  contraction.  This  extension 
and  subsequent  contraction  limits  the  excursions  of  the  breast,  pulls 
the  nipple  down  into  the  gland  {retraction  of  the  nipple),  and,  tlirough 
the  ligamenta  suspensoria  of  Sir  Astley  Cooper,  causes  the  typical 


Fig.  741. — Atrophic  or  withering  scirrhus  of 
breast.  Age  seventy-five  years;  growth 
noticed  only  a  little  over  a  year  ago;  ulcer- 
ated for  six  months.  Has  had  no  treatment, 
and  the  growth  is  now  adherent  to  the  ribs 
and  inoperable.    Episcopal  Hospital. 


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SCIRRHOUS  CARCIXOMA 


111 


(liiiipling  of  tlie  overlying  skin  resembling  an  orange  or  pig  skin. 
Tims  qnite  early  the  overlying  skin  beeomes  fixed  to  the  growth, 
and  the  growth  beeomes  fixed  to  the  pectoral  fascia.  The  axillary 
lyinphatirs  are  not  j)alpably  enlarged  early  in  the  disease,  bnt  they 
are  microscopically  invaded  long  before  they  become  palpable.  The 
diagnosis  shonld  be  made  before  this  complication  or  ulceration  of  the 
skin  tlevelops.  llccraiion  is  a  late  stage  of  the  disease,  usually  not 
appearing  for  one  or  two  years  after  the  development  of  the  tumor. 
In  some  cases  (atrophic  scirrhus)  ulceration  may  never  occur.  When 
it  develops  it  is  due  to  gradual  in\'asion  of  the  skin  by  the  cancerous 
growth;  a  small  ulcer  first  ai)pears,  and  this  gradually  increases  in 
size.  The  scirrhous  ulcer  is  quite  typical:  it  is  more  or  less  circular 
in  outline,  fixed  to  the  chest  wall,  red,  dry,  and  quite  dense;  colloqui- 
ally it  is  known  as  the  ^' rose  ulcer"  (Fig.  742).     Occasionally  as  a 


Fig.  742. — Scirrhous  carcinoma  of  breast  showing  typical  "rose  ulcer."  Age  sixty- 
eight  years;  duration  three  years;  ulcerated  six  months.  Has  had  no  treatment,  and 
growth  is  now  adherent  to  ribs  and  inoperable.  Two  years  and  six  months  later,  there 
was  a  large  stinking  ulcer,  patient  was  extremely  emaciated,  hardly  able  to  stand,  and 
suffered  dreadful  pain.    Episcopal  Hospital. 


primary  growth,  but  more  often  as  a  recurrence  after  operation, 
carcinoma  grows  either  in  many  apparently  isolated  spots  over  the 
chest  wall,  or  widely  diffused  in  the  skin;  this  is  known  as  "squirrhe 
en  cuirasse,"  as  if  the  patient  was  covered  with  a  "coat  of  mail" 
composed  of  carcinomatous  nodules  (Fig.  744). 

Prognosis  and  Treatment. — Owing  to  the  slow  growth  and  few 
subjective  symptoms  produced  by  the  tumor,  the  patient  often 
does  not  seek  surgical  advice  until  fixation  and  perhaps  ulceration 
have  occurred.  The  average  duration  of  life  in  untreated  cases  of 
scirrhus  is  from  two  and  a  half  to  three  years.  The  more  atrophic 
the  type,  the  longer  will  death  be  delayed;  sometimes  the  patient 
drags  out  a  painful  existence  for  twenty  years.  If  radical  operation 
is  done  before  fixation  of  the  tumor,  so  that  it  is  possible  to  remove 
all  of  the  disease,  freedom  from  recurrence  for  three  years  or  more 
(which  is  classed  as  "ultimate  cure")  will  result  in  from  50  to  70 


718  SURaEKY  OF  THE  BREAST 

per  cent,  of  cases  so  treated.     The  reasons  why  operation  should  be 
urged,  even  with  no  better  prospects,  are  stated  at  p.  725;  and  the 


I"  ^1'^' — ^'^rcinoma  simplex  of  left  breast.  Age  forty-four  j-ears;  duration  seven 
months  from  recurring  trauma  from  work  in  mill.  Note  pig-skin  dimpling,  retraction 
of  nipple,  breast  standmg  out  from  thorax;  emaciated  face,  and  anxious  expression. 
(See  Fig.  744.)     Episcopal  Hospital. 


Fiu.  744. — Recurrent  carcinoma  of  breast  one  year  aftf  r  oxci^ion.  Note  cancer  en 
cuirasse,  fatter  face  and  less  anxious  expression  since  being  under  hospital  care;  edema 
of  left  arm;  involvement  of  right  axilla.  Two  and  a  half  years  after  operation,  condition 
no  worse,  growth  seemingly  held  in  check  by  constant  i-ray  treatments.  (Dr.  Thos.  S. 
Stewart.)     Xo  pain,  less  edema  of  arm.    Episcopal  Hospital. 

question  of  operabiHty  is  discussed  in  the  same  place.     In  inoperable 
cases  palliative  treatment,  as  outlined  in  Chapter  IX,  is  indicated. 


I'AdKT'S   DISKASh-  OF   Tlll<:   MI'I'IJ':  719 

Carcinoma  Simplex  or  Acute  Scirrhus  is  an  iiitcrnu'dicite  form  between 
the  scirrhous  and  incihiMary  t\|)('s.  The  tumor  causes  increase  in 
the  si/e  of  the  hreast,  and  ^rows  rai)idl\';  the  axilhiry  lymphatics 
are  i)alj)al)I\'  in\ oh'cd  (juite  early  in  the  disease,  and  all  local  symptoms 
(limitation  of  excursion  of  tlie  hreast,  retraction  of  the  nipple,  orange 
skin  dimpliufi)  occur  sooner  than  in  the  scirrhous  form  fFig.  748). 
Ulceration  also  develops  earlier  and  the  ulcer  is  deeper  hut  is  not 
fixed  to  the  chest  wall;  its  surface  is  covered  with  slouj^hs,  there  is 
more  dischar<ie,  and  hemorrhages  may  occur  (Fig.  74()j. 

Prognosis  inul  Treatment. — On  account  of  the  more  rapid  growth 
of  the  tumor,  tiie  patient  usually  seeks  advice  sooner  than  in  the 
scirrhous  form,  and  therefore  radical  treatment  more  often  can  be 
undertaken  with  a  hope  of  cure. 

Medullary  Carcinoma  is  much  rarer  than  either  scirrhus  or  carcinoma 
simi)lex.  The  tumor  occurs  in  younger  women,  and  is  of  extremely 
raj^id  growth,  often  simulating  a  phlegmonous  process.  The  over- 
lying skin  is  red  and  tense;  the  breast  is  covered  with  dilated  veins, 
and  feels  hot  on  ])alpation;  soft  areas  resembling  suppurating  cysts 
or  abscesses  may  be  felt;  and  in  the  course  of  a  few  weeks  the  whole 
surface  of  the  tumor  breaks  down,  and  a  foul,  sloughing  mass  pro- 
trudes. Hemorrhages  are  frequent,  and  large  clots  may  cover  the 
surfaces  of  the  mass  (Fungus  Hematodes).  On  section  the  tumor 
often  resembles  softened  brain  matter,  whence  it  sometimes  is  called 
encephaJoid;  it  is  friable  and  pulpy.  An  extreme  type  of  medullary 
carcinoma,  with  most  alarmingly  rapid  growth,  is  described  as  car- 
cinoniafoiis  mastitis.     This  often  involves  both  breasts. 

Prognosis  and  Treatment. — Death  usually  occurs  within  a  few 
months,  even  early  radical  operation  proving  ineffectual  in  preventing 
recurrence.  Those  tumors  developing  during  pregnancy  are  the  most 
malignant  of  all. 

Paget's  Disease  of  the  Nipple. — This  was  described  by  Sir  James 
Paget,  in  1874,  as  a  form  of  dermatitis  or  eczema  predisposing  to 
carcinoma  of  the  breast.  It  is  a  rare  disease,  and  while  almost  all 
ca.ses  occur  in  the  nipj)le  of  the  female  breast,  a  few  have  been  recorded 
as  occurring  in  other  parts  of  the  body.  The  exact  nature  of  the 
affection  is  still  disputed  by  pathologists.  Most  authorities  consider 
it  carcinomatous  from  the  beginning,  but  its  point  of  origin  is  un- 
determined. Some  hold  that  it  arises  in  the  galactophorous  ducts 
and  invades  the  skin  secondarily;  others  believe  that  it  originates  in 
the  epidermis  and  invades  the  ducts  secondarily.  Microscopically 
the  characteristic  feature  is  the  presence  of  large  transparent  multi- 
nucleated cells  ("Paget  cells")  in  the  deeper  layers  of  the  epidermis. 
Clinically  the  disease  aft'ects  women  of  the  cancer  age;  it  begins  as  a 
scaly  affection  of  the  nipple,  typically  eczematous  in  nature  but  totally 
uninfluenced  by  local  remedies  usually  effectual  in  relieving  eczema 
in  other  parts  of  the  body.  As  the  disease  progresses,  the  areola  is 
involved,  and  the  erosion  or  excoriation  continues  to  spread  super- 
ficially for  months  before  the  glandular  tissue  is  noticeably  affected. 


"20 


SURGERY  OF  THE  BREAST 


The  area  usually  is  moist,  but  some  psoriasis-like  cases  have  been 
reported.  The  subjective  symptoms  are  itching,  tingling,  and  burning; 
but  the  general  health  is  not  impaired. 

Treatment. — Treatment  consists  in  amputation  of  the  breast  as 
soon  as  the  disease  is  recognized;  if  the  disease  is  extensive  or  of  long 
duration,  it  is  safer  to  do  a  radical  operation  as  for  carcinoma. 

Cancer  Cyst. — This  is  the  rarest  form  in  which  malignant  disease 
of  the  breast  occurs.  It  has  been  studied  by  Bloodgood  (1907). 
Usually  occurring  as  a  single  cyst,  it  grows  slowly,  and  presents 
few  clinical  signs  of  malignancy.  Exploratory  operation  being  under- 
taken, the  cyst  is  found  to  contain  bloody  fluid,  and  there  is  no  intra- 
cystic  papillomatous  out-growth  to  account  for  this  fact;  but  usually 
an  indurated  or  ulcerated  area  is  found  in  the  cyst  wall.  Any  cyst 
which  is  opened  at  operation,  and  is  found  to  contain  hemorrhagic 
fluid,  should  be  looked  upon  as  carcinomatous  unless  there  is  an 
intracystic  papilloma  to  account  for  the  blood. 

Treatment  consists  in  radical  operation  as  for  other  forms  of  car- 
cinoma. 

Extension  of  Mammary  Carcinoma. — Local  extension  occurs  especially 
to  the  o\-erlying  >kin,  to  all  portions  of  the  mammary  gland  and  its 

ramifications,  and  to  the  sur- 
rounding adipose  tissue.  The 
deep  fascia  overlying  the  pec- 
toral muscles  and  as  far  down 
as  the  epigastrium  is  widely 
infiltrated,  and  early  invasion 
of  the  pectoralis  major  muscle 
may  occur,  as  demonstrated  by 
Heidenhain  (1S89). 

Lymphatic  extensions  are  di- 
rectly continuous  with  the  main 
growth  by  fine  columns  of  cancer 
cells.  As  the  primary  tumor  in 
most  cases  is  in  the  upper  outer 
quadrant  it  is  the  axillary  lym- 
phatics that  are  first  invaded  as 
a  rule,  and  this  invasion  occurs 
long  before  the  nodules  are  pal- 
pable. In  most  cases  the  nodes 
which  first  become  palpable  are 
those  on  the  side  of  the  thorax,  about  midway  between  the  axillary 
folds.  Let  the  patient's  arm  hang  by  her  side,  so  as  to  relax  the 
axillary  fascia,  and  then  palpate  gently  and  attentively  in  this  region. 
But  in  the  case  of  a  growth  in  the  extreme  upper  and  outer  part  of 
the  gland,  early  extension  may  occur  to  the  nodes  highest  in  the 
axilla,  and  these  rarely  can  be  palpated.  In  time  all  the  axillary 
lymphatics  are  involved,  and  even  the  supraclavicular  nodes  may 
become  enlarged.     In  advanced  cases  lymphedema  of  the  arm  results 


■ 

■ 

^^^ 

/ 

€ 

^H 

BES^"*   ■ 

1 

1 

u 

Fig.  745. — L^niijhatics  of  the  breast  and 
axilla,  involved  in  mamniarj-  carcinoma. 
Episcopal  Hospital. 


RADICAL  OPERATION  FOR  MAMMARY  CARCINOMA        721 

from  the  axillary  lyinpliatic"  oljstruction;  venous  obstruction  may  also 
contribute  to  the  edema;  and  pain  from  compression  of  the  axillary 
nerves  may  be  a  very  distressitiff  symjitom.  Lymphatic  extension 
may  also  occur  to  the  mediastiinmi,  especially  if  the  tumor  grows 
in  one  of  the  inner  quadrants  of  the  breast;  or  extension  may  occur 
across  the  middle  line  of  the  body  to  the  other  breast,  or  even  to 
the  other  axilla.  Both  breasts  and  both  axillae  always  should  be 
examined  attentively.  Finally  reference  must  be  made  again  to 
cancer  en  ciiira.s.sr,  due  to  widespread  carcinomatous  lymphangeitis 
of  the  skin. 

Distant  metastases  by  way  of  the  blood-stream  are  denied  by  modern 
pathologists.  Cancer  cells  in  the  blood  excite  thrombosis,  and  the 
thrombus  as  it  organizes  usually  destroys  or  renders  them  harmless 
(Handley).  Ilandley  has  also  indicated  that  bone  lesions  (confined 
to  the  bones  of  the  trunk,  the  proximal  ends  of  the  limbs,  and  the 
skull)  are  in  direct  continuity  with  the  main  growth;  their  site  often 
is  suggested  by  the  presence  of  subcutaneous  nodules  over  the  affected 
bone,  even  before  bone  pains,  or  pathological  fracture  demonstrate 
their  existence.  In  cases  of  scirrhus  this  sad  event  occasionally 
occurs  before  the  local  tumor  is  noted;  and  it  is  a  rule  always  to 
consider  the  possibility  of  already  present  metastases  before  operating 
on  a  case  of  scirrhus,  and  always  to  inquire  into  the  condition  of  the 
mammary  gland  in  the  case  of  obscure  malignant  growths  in  the 
bones  or  viscera. 

Radical  Operation  for  Mammary  Carcinoma. — Ablation  of  the  Breast. — 
The  general  principles  on  which  a  radical  operation  for  malignant 
disease  is  based  were  discussed- in  Chapter  IV  (p.  132).  The  develop- 
ment of  the  technique  of  the  modern  operation  for  carcinoma  of  the 
breast  is  due  largely  to  the  teaching  of  C.  H.  ]\Ioore,  Volkmann, 
Heidenhain,  Stiles,  Halsted,  and  Ilandley.  Moore  (1867)  was  one 
of  the  earliest  to  discard  the  theory  of  a  cancerous  diathesis,  and  to 
look  upon  it  as  a  disease  of  purely  local  origin;  in  consequence  he 
urged  wide  excision  of  the  breast  and  all  involved  structures  (pectoral 
fascia  and  muscle  and  enlarged  lymphatics)  in  one  mass.  Volkmann 
(1875)  always  excised  the  pectoral  fascia  and  emphasized  the  necessity 
of  removing  the  surface  of  the  pectoral  muscles  when  diseased,  and 
established  the  "three  year  limit,"  all  patients  free  from  recurrence 
after  this  interval  being  reckoned  as  "cures."  Though  recurrences 
(or  perhaps  new  carcinomas)  may  grow  after  intervals  of  ten  and 
even  twenty  or  more  years,  it  is  found  by  the  best  operators  today 
that  recurrence  after  a  free  interval  of  three  years  occurs  in  only 
about  20  per  cent,  of  patients.  Heidenhain  (1889)  urged  removal 
of  the  surface  of  the  pectoral  is  major  muscle  in  all  cases,  even  when 
not  visibly  diseased,  as  on  microscopic  examination  he  found  it  always 
invaded  by  cancer  cells.  Stiles  (1892)  called  renewed  attention  to 
the  importance  of  wide  local  excision,  showing  the  great  area  over 
which  the  mammary  gland  was  spread  out — sending  processes  to  the 
clavicle  above,  to  the  axilla  laterally,  and  well  below  the  lower  border 
46 


722 


SURGERY  OF  THE  BREAST 


of  the  pectoralis  major,  on  to  the  serratus  magnus,  rectus,  and  external 
oblique  muscles.  Halsted  (1894)  introduced  removal  of  the  pectoralis 
major  as  a  measure  of  routine,  to  facilitate  clearing  the  axilla,  in 
every  case,  whether  the  axilla  was  manifestly  diseased  or  not;  and  he 
also  insisted  that  the  supraclavicular  lymph  nodes  should  be  excised, 
and  that  the  entire  diseased  tissue  should  be  removed  in  one  piece. 
Willy  Meyer  in  the  same  year  urged  removal  of  the  pectoralis  minor 
in  every  case,  and  renewed  the  advice  of  Gerster  (1885),  who  had 
advocated  commencing  the  operation  by  the  axillary  dissection, 
which  was  left  by  others  for  the  last  step,  and  usually  was  under- 
taken only  after  the  main  tumor  mass  had  been  cut  away.  Finally-, 
Handley,  in  his  Astley  Cooper  prize  essay  (1905),  demonstrated 
anew  the  importance  of  the  deep  fascia  as  the  main  highway  by  which 
the  carcinoma  cells  spread  in  all  directions  from  the  common  centre 
of  disease,  and  has  shown  the  necessity  of  removing  it  in  a  wide 
circle  on  all  sides  of  the  growth,  which  should  be  taken  as  a  centre, 
the  circumference  to  which  excision  should  extend  having  as  radius 
the  distance  from  the  tumor  to  the  clavicle.  This  excision  extends 
laterally  to  the  latissimus  dorsi,  medially  well  beyond  the  middle 
line,  and  inferiorly  at  least  two  inches  below  the  ensiform  process.^ 

The  operation  thus  comprises  removal  of  a  very  wide  area  of  skin, 
the   mammary  gland   with  surrounding  fat,  the  deep  fascia,   both 

pectoral  muscles,  and  axillary 
lymi)hatics,  in  one  viass.  If  this 
diseased  mass  is  cut  into  at  any 
point  the  contained  cancer  cells 
will  be  given  a  chance  to  escape 
into  the  surrounding  healthy  tis- 
sues, and  recurrence  will  be  very 
apt  to  follow.  For  the  same 
reason  all  rough  handling  and  tear- 
ing the  tissues  apart  by  blunt 
dissection  should  be  avoided. 

Skin  Incision. — So  long  as  this 
removes  a  sufficient  area  of  skin, 
its  particular  form  is  immaterial. 
A  wound  which  cannot  be  closed 
completely  is  less  likely  to  be  the 
seat  of  recurrence  than  one  which 
can,  because  there  is  less  likeli- 
hood of  diseased  tissue  remaining. 
I  prefer  Jabez  N.  Jackson's  (Fig. 
746)  incision  (190(3)  for  early  cases 
with  little  apparent  involvement  of  the  skin.  For  the  average  case 
Rodman's  incision  is  as  good  as  any  (Fig.  747).  Only  a  portion  of  the 
incision  is  made  at  first,  sufficient  for  the  dissection  of  the  axilla, 
which  should  constitute  the  first  step  in  the  operation.  To  postpone 
this  to  the  last,  as  in  Halsted's  method,  leaves  the  entire  thoracic 


Fig.  746. — Jackson's  incision  for  fani- 
noma  of  the  breast,  suitable  for  early 
cases.  The  rectangular  flap  is  turned  down- 
ward and  the  axillary  flap  upward  in 
closing  the  wound.      Episcopal  Hospital. 


RADICAL  (H'Kh'A'I'IOX    FOh'    M A  M M A  h'Y   CARCINOMA 


'28 


wound  rx])ose(l  (lurinjij  the  most  tedious  part  of  the  oiH'ration;  whereas, 
it'  the  axilhi  is  cleared  first  (and  this  may  re((uire  two  liours  or  more 
in  (hfhcult  eases)  the  remainder  of  tiie  operation  may  he  eoinpleted 
in  ahont  fifteen  minutes.  Moreover,  the  hhxxl-supply  is  eontrolled 
nnieh  more  (>ii"eetively  if  each  branch  going  to  the  tumor  mass  is 
secured  at  its  origin. 

Tlie  i)eetorahs  major  nuiscle  is  exposed  first,  its  upi)er  border 
identified,  chimping  or  protecting  the  cejjhalic  vein.  A  finger  is 
tlien  passed  beneath  tiie  muscle, 
and  it  is  di\ided  close  to  its 
humeral  attachment.  The  cla- 
\icular  fibres  of  the  jjectoralis 
major  are  next  cut  close  to  the 
bone.  This  exposes  the  pector- 
alis  minor,  which  is  similarly 
divided  close  to  the  coracoid 
process,  and  the  axilla  is  fully 
exposed.  If  there  are  palpably 
enlarged  lymph  nodes  at  the  apex 
of  the  axilla,  the  skin  incision 
should  })e  extended  upward 
across  the  clavicle,  and  the 
supracla\'icular  nodes  explored. 
If  enlarged  they  should  be  re- 
moved. I'nfortunately  it  is  not 
feasible  to  remove  them  in  one 
mass  with  the  axillary  lymph- 
atics, and  they  must  be  excised 
separately.  Then  the  axilla  is 
cleared  from  above  downward, 
working  along  the  axillary  vessels 
to  the  lower  border  of  the  latis- 

simus  dorsi.  Arterial  and  venous  branches  are  clamped  and  cut  close 
to  the  main  trunks.  Whenever  the  supply  of  hemostats  is  exhausted, 
all  clamped  points  should  be  ligated,  thus  releasing  the  hemostats  for 
future  use.  The  main  nerve  trunks  are  carefully  preserved,  as  is  the 
median  (long)  subscapular  nerve  which  supplies  the  latissimus  dorsi; 
injury  to  this  will  affect  the  usefulness  of  the  arm.  Sensory  nerves 
may  be  cut  without  compunction.  When  the  vessels  once  have  been 
dissected  free  the  operation  may  proceed  with  greater  rapidity.  The 
entire  axillary  contents  are  turned  toward  the  chest,  and  the  lateral 
thoracic  wall,  from  behind  forward,  is  denuded  of  fascia;  here  the  long 
thoracic  ne^^'e  (external  respiratory)  should  be  looked  for  and  pre- 
served.    The  axillary  wound  is  then  filled  with  gauze. 

The  skin  incisions  are  gradually  extended  to  outline  the  breast, 
and  are  extensively  undermined,  on  all  sides,  leaving  attached  to 
them  only  enough  superficial  fat  to  prevent  sloughing.  The  axillary 
contents  and  pectoral  muscles  are  then  turned  toward  the  median 


Fig.  747. — Rodman's  incision  for  carci- 
noma of  the  breast,  suitable  for  most 
cases.  The  triangular  flap  below  the 
clavicle  is  pulled  downward,  and  the  under- 
mined skin  on  the  lateral  surface  of  the 
thorax  is  pulled  upward,  the  wound  being 
sutured  in  the  form  of  the  letter  T,  the 
long  limb  lying  in  the  long  axis  of  the 
breast.    Episcopal  Hospital. 


724 


SURGERY  OF  THE  BREAST 


line,  and  the  dissection  of  the  chest  is  continued  from  the  lateral 
wall  to  the  sternum.  Here  the  perforating  branches  of  the  intercostals 
and  internal  mammary  arteries  will  be  encountered,  and  may  cause 
troublesome  bleeding  if  allowed  to  retract  below  the  intercostal 
muscles  before  being  clamped.  The  tumor  mass  now  })eing  free  above, 
the  dissection  is  continued  downward,  removing  the  deep  fascia  over 
the  upper  portir)n  of  the  rectus  muscle  in  the  epigastric  region. 


Fig.  748. — Ablation  of  the  breast:  the  pectoralis  major  has  been  cut  near  its  humeral 
insertion,  and  its  clavicular  fibres  have  been  divided,  exposing  the  pectoralis  minor. 
The  entire  skin  incision  (indicated  in  the  drawing)  is  not  made  at  one  time,  but  only 
as  the  operation  proceeds. 

The  tumor  being  thus  removed,  a  puncture  for  drainage  is  made 
in  the  skin  of  the  axilla,  and  a  tube  introduced.  This  is  allowed  to 
remain  four  or  five  days.  The  skin  is  then  sutured,  closing  the  wound 
as  far  as  can  be  done  without  undue  tension.  The  arm  is  dressed  in 
a  fully  abducted  position;  this  permits  more  accurate  apposition  of 
the  skin  to  the  axilla,  prevents  accumulation  of  wound  discharges 
here,  and  facilitates  return  of  the  function  of  the  upper  extremity. 
When  the  skin  is  accurately  adjusted  to  support  the  axillary  struc- 
tures, it  is  very  seldom  that  disability  follows  from  cicatricial  con- 
traction. Lymphedema  may  develop  after  the  operation,  especially 
when  a  thorough  removal  of  the  axillary  lymphatics  has  been  accom- 
plished. It  may  be  treated  by  Plandley's  operation  (p.  270).  Excel- 
lent motion  is  retained  by  the  arm  in  spite  of  removal  of  both  pectoral 
muscles,  and  the  patient  is  little  if  at  all  inconvenienced  by  their  loss. 
Murphy  retains  them  as  pads  to  fill  up  the  hollow  of  the  axilla,  and 
removes  the  breast  before  beginning  his  axillary  dissection.  Few 
or  no  surgeons  any  longer  approve  of  this  method  of  operating. 
Tansini  slides  a  musculo-cutaneous  flap  from  the  back  across  to  the 
thoracic  wound,  permitting  of  its  complete  closure  in  every  case. 

The  immediate  mortal  if  y  of  the  extensive  operation  described  above 
is  very  low — not  more  than  1  per  cent,  in  skilled  hands.  Deaths  are 
caused  almost  solely  by  visceral  complications,  such  as  pneumonia, 
cardiac  disease,  or  uremia. 


RADICAL  OPERATION  FOR  MAMMARY  CARCINOMA        725 

Affrr-irfatmrnt.-W'hvn  the  iiu-ision  cannot  bo  sntiircfl  completely, 
some  surgeons  prcl'(T  to  do  skiii-^'riiftiii},^  at  the  <-oii(lusioii  ot"  the 
operation;  while  others  postpone  this  niitil  ^frainilation  has  commenced. 
Personally  I  believe  it  is  better  to  do  ni'ither,  bnt  to  expose  the  frramj- 
lating  surface  to  the  .r-ray  at  suitable  intervals.  If  this  treatment  is 
conducted  by  a  skilled  nintucnolo^ist,  there  seems  nuich  less  tendency 
to  recurrence,  and  where  inoperable  recurrence  takes  ])lace  this  treat- 
ment greatly  relieves  the  pain,  diminishes  the  discharge  and  fetor, 
and  keeps  the  })atients  comfortable  (Figs.  740  and  744). 

Examination  of  the  wound  for  recurrence  should  be  insisted  ujjon, 
at  first  monthly;  then  every  three  or  four  months,  until  the  three 
year  i)erio(l  has  elapsed.  After  this  time  the  patient  should  rej)ort 
to  her  surgeon  at  least  once  a  year,  or  immediately  if  any  sj'mptoms 
arise. 

End  RrsuJts  of  tlir  RadicaJ  Operation  for  ('(ircinonia  of  the  Breast. — 
If  the  oi)eration  is  done  in  favorable  cases  (before  there  is  ])alpal)le 
axillary  involvement  and  before  the  tumor  is  fixed  or  the  overlying 
skin  ulcerated),  about  70  per  cent,  of  patients  will  be  "cured"  in 
Volkmann's  sense;  that  is,  they  will  remain  free  of  recurrence  for  a 
period  of  three  years.  And  of  these  clinical  "cures,"  only  about  one- 
fifth  will  have  a  recurrence  at  a  later  date.  If  axillary  invasion  has 
occurred  before  the  operation  is  done,  about  25  per  cent,  of  patients 
will  be  in  good  health  after  three  years.  These  figures  are  conserva- 
tive, as  better  results  are  reported  by  those  who  do  most  of  these 
operations. 

But  the  advantages  of  the  operation  are  great  even  if  recurrence 
or  metastasis -eventually  occurs.  At  the  very  worst,  the  patient 
will  enjoy  a  number  of  months,  perhaps  several  years,  of  good  health, 
and  will  have  hope  of  ultimate  cure.  Even  if  recurrence  takes  place 
a  cure  may  still  be  possible  by  aid  of  a  second  or  third  operation. 
Finally,  if  metastasis  occurs,  and  death  results  from  this  cause,  it 
will  be  a  very  much  less  painful  death  than  that  from  local  recurrence, 
and  the  operation  at  least  will  have  prolonged  life  and  afforded  an 
interval  of  comfort  and  of  hope. 

Inoperable  Cases. — Usually  no  operation  should  be  undertaken 
in  cases  in  which  it  is  manifestly  impossible  to  remove  all  of  the 
disease.  In  most  patients  wdth  the  supraclavicular  nodes  palpably 
enlarged,  no  operation,  however  radical,  wdll  effect  a  cure;  but  if 
the  tumor  is  not  otherwise  inoperable,  the  radical  operation  may  be 
done,  these  nodes  being  removed  at  a  second  operation  ten  days  or 
two  weeks  later.  Only  if  they  are  very  slightly  involved  is  it  safe 
to  prolong  the  original  operation  for  their  immediate  removal. 

Recurrences  are  to  be  treated  on  the  same  principles  as  the  primary 
growth.  Even  fixation  to  the  chest  wall  does  not  necessarily  contra- 
indicate  excision;  the  portions  of  ribs  invaded  may  be  removed. 

Palliative  operations  sometimes  are  done  in  inoperable  cases.  Very 
occasionally  mere  "  ampidation"  of  the  breast  (p.  710),  to  remove 
a  sloughing  ulcer,  followed  by  x-ray  treatment,  will  promote  the 


■2() 


SURGEJiY  OF  THE  CHEST   WALL 


patient's  comfort  and  prolong  life  even  when  cure  is  out  of  the  question 
(Fig.  740).  Cauterization  with  the  actual  cautery,  or  with  chemicals, 
such  as  chloride  of  zinc  solution  (5  per  cent.),  sometimes  will  relieve 
discomfort  by  sterilizing  the  surface  of  a  sloughing  growth.  Double 
oophorectomy,  introduced  by  Beatson  of  Glasgow,  in  1890,  has  been 
employed  in  a  number  of  advanced  cases,  and  in  some  patients  shrink- 
age of  the  breast  tumor  and  considerable  relief  has  followed.  Ampu- 
tation at  the  shoulder-joint  was  employed  by  Esmarch  (1883)  as  a 
primary  operation  in  one  far  advanced  case,  and  has  been  practised 
a  number  of  times  since  in  cases  of  recurrence;  and  even  interscapulo- 
thoracic  amputation  has  been  employed  in  cases  of  recurrence  (Dent, 
in  1897,  and  later  by  others).  Others  have  employed  rhizotomy 
(p.  530),  with  marked  relief  of  pain. 


SURGERY  OF  THE  CHEST  WALL. 

Congenital  and  Acquired  Malformations. — These  are  of  interest 
from  a  diagnostic  point  of  view,  but  little  can  be  done  in  the  way 
of  treatment.  Birth  i)ijuries  occasionally  result  in  deformities  which 
persist  through  adult  life  (Fig.  749),  but  seldom  entail  any  disability. 
The  diagnosis  is  made  from  the  history.    Rachitic  deformities,  reference 


Fig.  749. — Birth  injury  of  thorax. 
Orthopaedic  Hospital. 


Fig.  750. — Fuuiiel   lireast    iracliiticj. 
Orthopaedic  Hospital. 


to  which  was  made  at  p.  418,  develop  during  infancy  or  early  child- 
hood, and  are  recognized  by  coincident  symptoms  of  rachitis.  The 
most  frequent  deformities  are  the  "rachitic  rosary,"  Harrison's 
groove,  and  pigeon  breast;  these  seldom  persist  past  the  age  of 
puberty.    Funnel  breast,  however,  may  last  through  life  (Fig.  7oO). 


Injuries 


Til 


Some  of  these  deforiuities  iiuiy  he  improved  by  gymnastic  exercises, 
t)r  by  tlie  use  of  ortliopedic  apparatus,  if  treatment  is  begun  in  early 
childhood;  but  the  disability  is  so  slight  in  adult  life  that  no  active 
intcrfiTcnce  is  required. 

Injuries. — The  most  frequent  injury  is  fracture  of  the  ribs.  This 
was  considered  at  p.  .S23.  Simple  contusions  require  no  special 
notice.  Severe  lacerated  wounds,  with  compound  fracture  of  the 
ribs,  usually  are  attended  by  visceral  injuries  (for  which  see  p.  73.'-{). 
They  arc  caused  by  crushing  injuries,  explosions,  etc.,  and  often  are 

fatal.  If  the  patient  survives,  con- 
valescence is  prolonged,  and  severe 
deformity  may  ensue   (Fig.  751). 

In  some  cases  a  phenomenon 
known  as  traumatic  asphyxia,  or 
stasis  cyanosis,  follow'S  sudden  vio- 
lent compression  of  the  chest  (or 
abdomen)  of  short  duration.  This 
state  is  characterized  by  marked 
cyanosis  of  the  head,  face,  and 
neck,    usually    sharply    delimited    a 


Fig.  751. — Deformity  of  thorax 
following  injury  by  explosion  in 
coal  mine.     Episcopal  Hospital. 


Fig.  752. — Traumatic  asphyxia;  oxygen  in- 
halations. Death  in  twelve  hours.  Episcopal 
Hospital. 


short  distance  above  the  clavicle,  apparently  by  the  collar.  The 
patient  looks  as  if  he  had  been  strangled  (Fig.  752):  the  eyes  are 
bloodshot,  and  the  eye-lids  may  become  edematous;  there  may  be 
hemorrhages  from  the  naso-pharynx  or  ears;  convulsions  or  uncon- 
sciousness may  occur.  In  addition  to  shock,  there  is  irregularity 
or  entire  failure  of  respiration.  The  cyanosis,  w^hich  is  petechial  in 
appearance,  may  be  due  to  extravasation  of  blood  (true  traumatic 
asphyxia)  or  to  dilatation  of  the  capillaries  with  blood  stasis  (stasis 
cyanosis).  It  is  difficult  to  differentiate  the  conditions,  which,  indeed, 
often  coexist.  The  mechanism  by  wdiich  this  state  is  produced  is 
believed  to  be  sudden  compression  of  the  thorax  with  the  glottis 
closed,  causing  violent  reflux  of  blood  from  the  right  heart.  There 
may  be  interstitial  and  subpleural  hemorrhages  in  the  lungs,  with 


728  SURGERY  OF  THE  CHEST  WALL 

interstitial  emphysema;  and  in  some  cases  cerebral  congestion  and 
hemorrhages  have  been  found  postmortem. 

Treatment. — Treatment  comprises  measures  to  o^'ercome  shock, 
with  artificial  respiration,  and  inhalations  of  oxygen.  The  pulmotor, 
a  mechanical  device  for  artificial  respiration  employed  in  cases  of 
poisoning  by  illuminating  gas,  may  be  used  with  advantage. 

Surgical  Emphysema. — Surgical  emphysema  is  a  term  used  to 
describe  the  esca])t'  of  air  into  the  subcutaneous  tissues.  As  previously 
noted  (p.  301)  it  may  occur  in  the  face  in  connection  with  fractures 
of  the  nose,  etc.  The  most  usual  form,  however,  is  that  due  to  thoracic 
injury;  and  the  air  escapes  across  the  pleura  from  the  lungs  which 
have  been  punctured  by  a  broken  rib  or  ruptured  by  the  compressing 
force.  If  the  emphysema  appears  first  at  the  root  of  the  neck,  and 
not  at  the  site  of  injury,  it  is  probable  that  the  rupture  of  the  lung 
is  entirely  subpleural,  and  that  the  air  has  escaped  into  the  loose 
cellular  tissues  surrounding  the  bronchi,  and  eventually  reaches  the 
neck  by  way  of  the  mediastinum.  This  subcutaneous  emphysema 
may  occur  without  any  clinical  evidence  of  severe  intra-thoracic 
injury,  but  as  auscultation  and  percussion  are  much  interfered  with 
by  its  development,  it  is  probable  that  the  deeper  lesions  often  are 
overlooked.  Occasionally  a  wound  of  the  pleura,  without  injury  of 
the  lung,  may  cause  the  development  of  emphysema,  the  outside  air 
being  sucked  into  the  wound  by  the  negative  intra-thoracic  pressure. 

The  air  may  spread  far  over  the  body,  up  to  the  scalp,  dowTi  to 
the  groin,  and  even  out  along  the  limbs;  the  eyes  may  be  closed  up, 
and  the  patient  may  become  so  bloated  that  recognition  will  be 
impossible.  Subjective  symptoms,  except  those  due  to  visceral 
lesions,  are  insignificant.  Palpation  of  the  areas  affected  produces 
typical  crackling;  the  skin  feels  as  if  floated  up  from  the  muscles  or 
bones  by  an  effervescing  liquid;  the  air  may  be  driven  from  one 
place  to  another  by  the  fingers,  and  pitting  on  pressure  is  apparent. 
The  larger  the  source  of  supply,  the  more  rapid  will  be  the  develop- 
ment and  spread  of  the  emphysema.  In  some  cases  only  a  very 
limited  area  is  affected,  and  attentive  examination  is  required  to 
detect  it;  in  others  the  emphysematous  area  increases  rapidly  in  size 
as  the  patient  is  watched. 

Treatment. — Mild  cases  require  no  treatment;  but  usually,  whether 
or  not  there  is  fracture  of  the  ribs,  the  injured  side  of  the  thorax 
should  be  strapped,  as  limitation  of  the  respiratory  excursions  will 
diminish  the  spread  of  the  air.  Where  the  emphysema  is  very  marked, 
it  has  been  recommended  that  multiple  pinictures  be  made  with  a 
fine  pointed  bistoury,  or  tenotome,  whereupon  air  will  escape  with 
a  hissing  noise,  and  the  swelling  will  partly  subside.  As  a  matter  of 
fact,  if  any  treatment  is  necessary,  it  is  much  better  to  aspirate  the 
pneumothorax,  since  as  long  as  this  continues  air  will  escape  from  it 
into  the  subcutaneous  tissues.  The  chief  danger  is  infection  of  the 
subcutaneous  tissues,  with  widespread  cellulitis.  Apart  from  this  and 
visceral  lesions,  the  prognosis  is  good. 


AXILLARY  ABSCESS 


r29 


Axillary  Abscess.  Tins  inn\-  he  .superficial  or  deep.  Tlu;  fcjrmcr, 
wliicli  i>  more  frt'(iiu'iit  and  loss  serious,  arises  in  connection  with  the 
hair  t'oUlck's  or  sehaceous  <jhin<ls,  as  a  furuncuh)sis;  the  process  occurs 
superficially  to  the  axillary  fascia.  I'sually  .suppuration  starts  in 
several  different  points,  but  if  incision  is  not  made  promptly  these 
may  coalesce  to  form  one  abscess  (Fig.  To']).  Trcaimeni  consists  in 
incision  and  drainage. 


Fig.    75.3. — Abscess  superficial    to   deep 
fascia  of  axilla.     Episcopal  Hospital. 


Fig.  7.54. — ^Deep  axillary  abscess, 
following  lymphadenitis;  duration  six 
weeks.     Episcopal  Hospital. 


Deep  or  True  Axillary  Abscess  arises  in  the  tissues  of  the  axilla 
underneath  the  axillary  fascia;  it  begins  as  lymphadenitis  (Fig.  754), 
and  usually  is  due  to  a  primary  infection  in  the  hand,  or  rarely  in 
the  breast.  Occasionally  these  deep  axillary  abscesses  point  through 
the  thin  (cribriform)  portions  of  the  axillary  fascia  and  present 
beneath  the  skin.  Rarely  the  pus  may  travel  upward  along  the  sheath 
of  the  axillary  vessels  and  point  at  the  root  of  the  neck.  Owing  to  the 
deep  seat  of  the  inflammation,  and  to  the  pus  being  covered  by  the 
dense  axillary  fascia,  distinct  evidences  of  suppuration  often  are 
absent.  The  surgeon  should  not  wait  for  fluctuation,  or  even  for 
redness  and  edema  of  the  overlying  skin,  or  other  classical  signs  of 
abscess.  The  subjective  symptoms,  pain,  tenderness,  and  loss  of 
function  of  the  arm,  are  so  severe  as  to  suggest  serious  trouble,  and 
the  constitutional  evidences  of  infection  may  be  marked.  Therefore 
no  time  should  be  lost  in  draining  the  axilla.  Usually  an  anesthetic 
is  desirable.  An  incision  is  made  from  the  outer  border  of  the  axilla 
inward  to  the  chest  wall,  midway  between  the  anterior  and  posterior 
axillary  folds.  After  the  skin  is  incised  the  knife  should  be  kept 
fairly  close  to  the  thorax,  \yhen  the  axillary  fascia  has  been  incised, 
if  pus  does  not  flow,  further  exploration  should  be  conducted  accord- 
ing to  Hilton's  method  (p.  51).  The  axilla  is  drained  by  a  tube,  and 
the  arm  is  carried  in  a  sling. 


730 


SURGERY  OF   THE  CHEST  WALL 


Subpectoral  Abscess. — This  is  an  abscess  between  the  pectoralis 
major  muscle  and  the  pectoralis  minor,  or  one  beneath  the  latter 
muscle,  at  the  extreme  apex  of  the  axilla.  Probably  in  most  cases 
it  is  caused  by  direct  contusion  or  strain  of  the  pectoral  muscle, 
producing  a  small  hematoma  which  subsequently  is  infected  through 
the  blood-stream.  It  may  arise  in  suppuration  of  the  subclavian 
lymph  nodes,  which  lie  on  the  anterior  surface  of  the  pectoralis  minor 
or  clavipectoral  fascia.  Sometimes  this  follows  infected  wounds  of 
the  thumb  or  index  finger  or  radial  aspect  of  the  forearm,  since  the 
lymphatics  from  these  regions  may  pass  du-ectly  to  the.se  nodes  along 
the  cephalic  vein;  whereas  the  lymphatics  from  other  regions  of  the 
hand  and  forearm  enter  the  axilla  with  the  brachial  vessels.  Rarely  a 
subpectoral  abscess  is  caused  by  caries  of  the  ribs,  or  by  bronchial 
or  pleural  infection;  in  such  cases  the  abscess  often  is  chronic  and  is 
due  to  tuberculosis  ^Tig.  758 j. 


Fig.  7.5.5. — -Right    subpectoral    a>>-  Fig.    7.50. — Abscess     in     left     supra.spinous 

scess;     duration    three    weeks.       Xo  fossa;    duration    one    week;    cause  unknown. 

cause   discoverable.     Episcopal   Hos-  Incision  evacuated  six  to  eight  ounces  of  pus. 

pital.  Healed  in  six  days.    Episcopal  Hospital. 


Symptoms. — A  subpectoral  abscess  forms  a  rounded,  tender,  painful 
swelling  below  the  inner  part  of  the  clavicle;  it  tends  to  point  at  the 
lower  border  of  the  pectoralis  major  (Fig.  755 j,  or  rarely  may  burrow 
through  an  intercostal  space  into  the  pleura.  It  is  differentiated  from 
axillary  abscess  by  its  position  nearer  the  median  line  of  the  body, 
and  by  the  relaxed  condition  of  the  axillary  fascia  and  freedom  of  the 
axilla;  and  from  arthritis  of  the  shoulder  by  the  slight  impairment 
of  the  movements  of  the  joint,  which  are  quite  free  within  a  limited 
range.  I  have  seen  the  condition  mistaken  for  tuberculosis  of  the 
shoulder-joint. 


CMilES  OF   rilE   h'lliS 


7'M 


Treatment. — Tlie  abscess  should  he  opened  hy  an  iiicisi(jii  aloiij^ 
the  lower  l)order  of  the  jjectorahs  major,  and  shoiihl  he  drained  with 
a  tiihc.     Musser  collected  2)^  cases  with  1)-)  deaths. 

Subscapular  Abscess.  This  is  (piite  rare.  The  pus  hjrnis  in  the 
space  hetwen  the  serratus  magnus  and  the  posterior  thoracic  wall. 
It  cannot  jioint  anteriorly  because  of  the  attachment  of  the  serratus 
ma^nnis  to  the  lateral  asjjcct  of  the  thorax;  it  cannot  escape  internally 
because  of  the  spinal  connections  of  the  scapula.  The  i)us,  therefore, 
spreads  either  upward,  and  points  beneath  the  trapezius,  which  is 
unusual;  or  downward  to  the  angle  of  the  scapula. 

If  the  existence  of  this  condition  is  remembered,  the  diagnosis 
rarely  will  be  difficult.  The  abscess  should  be  opened  at  the  lower 
angle  of  the  scapula,  and  drained.  In  some  cases  the  body  of  the 
bone  may  be  trephined. 

Suprascapular  Abscess. — Suppuration  in  the  supraspinous  fossa  is 
another  unusual  condition  (Fig.  ToO).  Unless  the  condition  is  borne 
in  mind,  the  swelling  may  be  mistaken  for  a  sarcoma.  The  onset 
usually  is  subacute,  and  maj'  follow  the  formation  of  a  hematoma  in 
the  supraspinatus  muscle  as  the  result  of  trauma;  or  the  lesion  may 
be  tuberculous  and  arise  in  the  bone.  The  abscess  should  be  opened 
and  drained,  unless  it  is  thought 
to  be  tuberculous,  when  it  should 
be  treated  as  a  tuberculous  ab- 
scess elsewhere  in  the  bo(h'  (p. 
483). 

Caries  of  the  Ribs. — This 
usually  is  tul)erculous  in  nature. 
It  may  be  due  to  extension  from 
a  focus  in  the  vertebrae,  or  from 
a  tuberculous  pleurisy;  or  the 
disease  may  be  primary  in  the 
ribs.  In  the  latter  case  devel- 
opment of  the  afTection  often 
follows  injury.  Usually  the 
patients  are  adults,  and  there 
often  is  pulmonary  tuberculosis 
or  a  tuberculous  lesion  in  the 
bones,  joints,  or  lymph  nodes. 
Early  formation  of  a  cold  ab- 
scess occurs,  and  this  presents 
itself  as  a  fusiform  swelling 
along  the  course  of  one  or 
more  of  the  ribs.  The  ribs 
from  the  third  to  the  eighth  are  oftenest  affected,  near  the  chondral 
or  the  vertebral  joints.  The  disastrous  results  of  spontaneous  fistu- 
lization  and  secondary  infection  are  as  prominent  here  as  elsewhere 
in  the  body  where  tuberculous  disease  is  concerned.  Interminable 
suppuration  ensues,  with  numerous  fistulse,  and  constant  pocketing 


Fig.  757. — Extensive  scars  of  both  hyper- 
chondriac  regions  from  previous  operations 
for  necrosis  of  ribs.     Episcopal  Hospital. 


732  SURGERY  OF  THE  ANTERIOR  MEDIASTINUM 

of  "hot"  pus,  which  requires  evacuation  (Fig.  757).  If  seen  before 
rupture  occurs,  the  abscess  should  receive  tlie  treatment  advised  for 
cold  abscess  in  general  (p.  483). 

Tuberculosis  may  also  affect  the  joints  of  the  sternum;  at  the 
junction  of  the  manubrium  and  gladiolus  its  development  has  been 
mistaken  for  fracture  (N.  B.  Carson). 

Acute  septic  osteomyelitis  of  the  ribs  may  occur,  but  is  rare;  also 
rare  is  typhoid  periosteitis  of  the  ribs,  which  may  not  develop  for 
months  or  years  after  the  attack  of  typhoid  fever.  Osteomyelitis 
may  result  in  necrosis  of  the  ribs,  and  resection  of  the  portions  affected 
may  be  required;  in  cases  of  typhoid  origin,  however,  curettement 
of  the  carious  surfaces  usuallv  is  sufficient. 


SURGERY  OF  THE  ANTERIOR  MEDIASTINUM. 

Affections  of  the  anterior  mediastinum  offer  up  to  the  present  a 
very  limited  field  for  surgical  care. 

Acute  Mediastinitis. — Acute  mediastinitis  is  the  term  used  for  a 
cellulitis  of  the  mediastinum.  It  may  follow  a  stab  or  gunshot  wound, 
or  may  result  from  extension  downward  of  a  cervical  cellulitis. 
There  are  pain,  tenderness  on  pressure  over  the  sternum,  and  con- 
stitutional symptoms  of  sepsis.  Signs  of  cardiac,  pulmonary,  or 
tracheal  compression  may  arise.  Usually  in  the  course  of  time  pus  is 
formed,  and  this  seeks  an  exit  for  itself  through  an  intercostal  space 
close  to  the  sternum,  or  possibly  by  rupture  into  a  bronchial  tube  or 
the  pleura.  Lymphadenitis  of  the  mediastinum  usually  is  tuberculous. 
The  onset  of  symptoms  is  less  acute  than  in  mediastinitis. 

Treatment. — When  medical  measures,  w'ith  cold  locally,  fail  to 
relieve  the  symptoms,  and  especially  when  symptoms  of  respiratory 
obstruction  arise,  surgical  intervention  is  called  for,  even  before 
pointing  of  an  abscess  occurs.  The  operation  consists  in  trephining 
the  sternum,  enlarging  the  opening  with  rongeur  forceps,  and  evacuat- 
ing the  pus  by  Hilton's  method  (p.  51).  An  abscess  may  be  opened 
where  it  points,  but  even  then  it  is  usually  necessary  to  cut  away 
part  of  the  sternum  to  secure  free  drainage. 

Mediastinal  Tumors. — These  give  evidence  of  their  presence  by 
compression  symptoms,  and  by  an  abnormal  area  of  dulness  on 
percussion.  Tuberculous  lymphadenitis  is  the  most  frequent  non- 
neoplastic growth.  The  lymphadenoid  enlargements  of  Hodgkin's 
disease  and  sarcoma  are  not  so  frequent  as  secondary  desposits  of 
carcinoma.  Benign  tumors,  especially  dermoids,  also  occur.  As  a 
rule  no  surgical  treatment  offers  any  prospect  of  cure;  but  palliation 
may  be  offered  by  splitting  the  sternum  longitudinally  to  lessen  the 
symptoms  of  compression.  Should  a  benign  tumor  be  found,  it  might 
be  removed  successfully.  Friedrich  recommends  transverse  section 
of  the  sternum  above  the  third  rib.  Enlargement  of  the  thymus 
gland  is  referred  to  at  p.  693. 


PENETRATING  WOUNDS  OF  THE   THORAX  733 

SURGERY  OF  THE  LUNGS  AND  PLEURA. 

Subcutaneous  Injuries.  Siilxutaiu'ous  injuries  of  the  thoracic 
viscera  usually  arc  accompanied  by  fractures  of  the  ribs  or  sternum; 
but  sometimes  tlie  hm<f  is  ruptured  without  there  being  any  coinci- 
dent injury  of  the  elastic  thoracic  cage.  In  most  cases  the  lung  is 
directly  crushed,  but  it  is  possible  for  it  to  be  injured  by  wTenching 
from  its  pedicle,  or  by  being  torn  loose  from  pleural  adhesions.  The 
extent  of  the  lesion  varies  from  mere  bruising  to  extensive  laceration, 
and  the  resulting  hemorrhage  may  be  slight  or  very  severe.  In  the 
mildest  cases  the  visceral  pleura  is  not  ruptured,  and  the  symptoms 
are  those  of  a  localized  pneumonia,  possibly  with  the  development 
of  subcutaneous  emphysema  commencing  at  the  root  of  the  neck 
(p.  728).  When  the  visceral  pleura  is  ruptured,  hemorrhage  occurs 
into  the  pleural  cavity,  and  the  air  also  usually  escapes  from  the 
lung,    forming   a    pneumo-hemothorax. 

Diagnosis. — The  diagnosis  depends  on  ascertaining  the  history  of  an 
injury;  on  the  symptoms,  which  do  not  differ  from  those  of  pene- 
trating wounds  of  the  lung  (see  below);  and  on  the  physical  signs 
of  pneumothorax  and  surgical  emphysema.  The  diflferential  diagnosis 
from  traumatic  diaphragmatic  hernia  may  be  difficult;  this  is  dis- 
cussed at  (p.  751). 

Treatment. — The  treatment  consists  primarily  and  chiefly  in 
rest,  either  in  the  recumbent  or  sitting  posture,  whichever  is  more 
comfortable  to  the  patient.  I  believe  the  administration  of  opium 
in  some  form  is  decidedly  beneficial,  allaying  the  annoying  cough, 
slowing  the  respiration,  and,  therefore,  diminishing  the  bleeding.  In 
many  cases  the  bleeding  stops  of  itself.  The  blood-pressure  in  the 
pulmonary  system  is  only  one-third  of  that  in  the  systemic.  If 
bleeding  does  not  cease,  as  indicated  by  persistent  symptoms  of 
internal  hemorrhage,  and  by  gradual  increase  in  the  amount  of  pleural 
effusion,  it  must  be  checked  by  operative  means,  as  described  below 
in  connection  with  penetrating  wounds  of  the  lung.  If  the  pneumo- 
thorax persists  and  causes  dyspnea,  the  air  may  be  aspirated;  for 
this  a  very  fine  needle  should  be  used,  as  less  liable  to  cause  sub- 
cutaneous emphysema.  The  surgeon  should  not  resort  to  this  measure 
unnecessarily,  since  relief  of  the  pneumatic  pressure  on  the  lung  may 
cause  recurrence  of  bleeding. 

Prognosis. — The  prognosis  is  grave  except  in  the  case  of  trivial 
lesions.  ]\Ioller,  in  1910,  reported  23  cases  from  Korte's  clinique; 
no  operation  was  attempted  in  any  case,  and  none  would  have  been 
of  any  avail  in  the  9  fatal  cases. 

Penetrating  Wounds  of  the  Thorax. — These  are  chiefly  gunshot 
or  stab  wounds.  The  former  have  been  considered  at  (p.  189).  In 
most  cases  of  stab  wounds  the  lung  is  injured,  but  penetration  of 
the  parietal  pleura  without  visceral  injury  is  possible.  In  the  latter 
case  intrapleural  hemorrhage  (hemothorax)  may  occur  from  injury 
of  a  vessel  in  the  thoracic  wall;  and  there  usually  is  pneumothorax, 


734  SURGERY  OF  THE  LUNGS  AND  PLEURA 

air  being  sucked  into  the  pleural  cavity  at  each  inspiration.  Com- 
plicating injuries  of  the  diaphragm  and  abdominal  viscera  are  fre- 
quent. If  the  lung  has  been  wounded  there  may  be  considerable 
shock,  Avith  dyspnea,  rough,  and  usually  spitting  of  blood  (hrinopfysis). 
In  many  cases  there  are  the  symptoms  of  severe  internal  hemorrhage 
(p.  227).  The  physical  signs  are  those  of  pneumothorax,  or  hemo- 
pneumothorax;  sometimes  there  is  hemorrhage  from  the  wound. 
Escape  of  air  from  the  wounded  lung  through  the  external  wound 
occasionally  occurs;  it  is  known  as  tranniaiopnea,  and  should  not 
be  confused  with  the  mere  aspiration  of  air  into  the  pleural  cavity 
such  as  was  described  as  occurring  even  when  no  pulmonary  injury 
is  present.  Prolapse  of  the  lung  through  the  wound  is  a  rare  occur- 
rence; this  should  not  be  confused  with  subcutaneous  hernia  of  the 
lung,  which  is  described  at  p.  73(5. 

Diagnosis. — Usually  this  is  not  difficult.  But  it  should  be  remem- 
bered that  alarming  intrapleural  hemorrhage  may  occur  from  injuries 
of  the  internal  mammary  and  intercostal  arteries,  without  wound  of 
the  lung;  and  the  possibility  and  extreme  seriousness  of  complicating 
stab  wounds  of  the  diaphragm  (p.  749)  should  be  kept  in  mind. 

Treatment. — The  constitutional  treatment  is  the  same  as  for  gun- 
shot wounds  or  subcutaneous  rupture  of  the  lung.  Under  no  cir- 
cumstances should  the  wound  be  explored  with  finger  or  probe. 
The  surrounding  skin  should  be  painted  with  3  per  cent,  alcoholic 
solution  of  iodin,  the  wound  should  be  covered  immediately  with 
sterile  gauze,  and  the  side  of  the  chest  affected  should  be  firmly 
strapped  as  in  the  case  of  fractured  ribs.  This  materially  alleviates 
the  patient's  pain,  though  probably  it  has  little  influence  on  the 
progress  of  the  wound  in  the  lung. 

The  question  of  the  propriety  of  early  operative  interference  in  thoracic 
injuries  has  been  the  subject  of  much  discussion  during  the  last 
few  years;  and  some  surgeons  are  very  uncompromising  in  their 
attitude  for  or  against  intervention.  The  debate  is  waged  chiefly 
over  the  subject  of  stab  wounds,  the  propriety  of  non-interference 
in  the  case  of  gunshot  wounds,  except  for  positive  indications,  being 
very  generally  recognized.  In  the  case  of  subcutaneous  injuries, 
also,  a  decision  for  or  against  operation  is  not  very  difficult,  because 
the  symptoms  either  are  so  trivial  as  never  to  raise  the  question,  or 
the  lesions  are  so  manifestly  lethal  in  extent  as  to  render  operation 
useless.  But  in  the  case  of  stab  wounds  there  are  those  who  teach 
that  operation  is  never  or  hardly  ever  required;  and  there  are  others, 
equal  in  experience  and  authority,  who  maintain  that  every  patient 
with  a  stab  wound  of  the  thorax,  seen  within  the  first  twelve  hours, 
should  be  taken  at  once  to  the  operating  room,  and  that  the  question 
of  operative  or  non-operative  treatment  should  be  decided  only 
after  an  exploratory  operation  has  been  done  to  determine  by 
inspection  the  extent  of  the  lesions.  Zeidler,  of  St.  Petersburg, 
with  an  immense  experience  in  this  class  of  cases,  takes  the  latter 
ground;  and  his  assistant  Lawrow  (1911)  has  exposed  his  views  very 


PENErRATING  WOUNDS  OF  THE   THORAX  735 

thoroughly.  Other  tilings  hcinjj  equal,  tliis  no  doubt  is  the  logieal 
position  to  take;  but  tlie  fact  remains  that  if  it  is  adhered  to,  a  great 
many  unnecessary  oj)erations  will  be  done;  and  in  many  cases  the 
patients  will  be  made  worse  or  will  be  killed  by  the  exploration. 

Most  surgeons  recognize  tiiat  stab  wounds  which  might  involve 
the  diaphragm  or  abdominal  viscera  should  be  explored;  and  the 
fact  that  oo  out  of  121  stab  wounds  of  tiie  thorax  (Lawrow)  came 
within  this  category  should  be  born(>  in  mind.  It  is  recognized, 
moreover,  that  wounds  which  probably  injure  the  heart  should  be 
explored  (p.  286);  according  to  Lawrow's  figures  only  one  out  of 
ten  stab  wounds  of  the  thorax  implicates  the  heart.  But  when  these 
two  classes  of  stab  wounds  are  excluded,  there  certainly  remains  a 
large  number  of  cases  in  which  it  is  at  least  extremely  proba})le  that 
only  the  lung  has  been  injured,  or  that  even  though  the  pleura  has 
been  penetrated  there  is  no  visceral  injury  whatever;  and  it  is  interest- 
ing to  compare  the  results  secured  in  the  case  of  uncomplicated 
pulmonary  wounds  in  Zeidler's  service,  where  every  patient  who  con- 
sented was  subjected  to  early  operation,  with  those  reported  (1910)  by 
IMoller  from  Korte's  clinique,  where  no  operations  were  done  in  such 
cases.  According  to  Zeidler's  immediate  exploration  plan  the  mor- 
tality in  52  uncomplicated  cases  was  27  per  cent.;  whereas  Korte 
treated  19  such  cases  without  one  death.  And  the  significance  of 
this  comparison  I  believe  is  not  altered  by  the  fact  that  in  78  per 
cent,  of  the  cases  explored  by  Zeidler  and  his  assistants  some  visceral 
injury  or  bleeding  from  an  intercostal  vessel  was  found. 

From  a  consideration  of  these  facts  I  think  it  is  evident  that  no 
hard  and  fast  rules  can  be  laid  dow^n  for  treatment,  but  that  each 
individual  case  must  be  treated  on  its  own  merits.  In  fully  equipped 
hospitals,  I  believe  exploratory  operation  for  stab  wounds  of  the 
thorax  will  be  indicated  more  often  in  the  future  than  in  the  past; 
certainly  more  often  than  in  the  case  of  gunshot  wounds  or  crushes. 
But  I  cannot  believe  that  exploration  in  every  case  is  necessary  or 
desirable.  If  there  is  a  possibility  of  injury  of  the  heart,  or  of 
the  diaphragm  or  abdominal  viscera,  exploration  is  imperative;  but 
if  this  possibility  seems  remote,  it  is  better  to  treat  the  patient 
expectantly. 

As  indications  for  operation,  then,  may  be  recognized  the  following 
factors : 

1 .  Possibility  of  injury  to  the  heart,  to  the  diaphragm,  or  abdominal 
viscera. 

2.  Active  hemorrhage  from  the  wound. 

3.  Signs  of  internal  hemorrhage,  recognized  by  constitutional 
symptoms,  and  by  steady  increase  in  the  amount  of  the  hemothorax. 
It  makes  no  difference  whether  this  comes  from  the  wounded  lung 
or  from  a  parietal  vessel.    The  bleeding  must  be  stopped. 

4.  Pneumothorax  which  develops  suddenly  some  days  after  the 
injury.  As  pointed  out  by  Moller  this  indicates  sloughing  or  reopening 
of  the  wound  in  the  lung;  and  immediate  drainage  of  the  pleura  is 


736  SURGERY  OF  THE  LUNGS  AND  PLEURA 

required  to  prevent  sepsis.  Primary  pneumothorax  scarcely  ever 
will  be  so  severe  as  to  demand  relief;  but  if  necessary  the  air  may 
be  aspirated  through  a  fine  needle.  If  this  fails,  the  only  relief  lies 
in  thoracotomy,  by  which  the  pressure  within  the  pleura  may  be 
reduced  to  that  of  one  atmosphere. 

Operation. — Usually  a  general  anesthetic  is  required.  Ether  is 
the  best,  and  if  possible  it  should  be  administered  by  intratracheal 
insufflation  (p.  154).  The  wound  is  carefully  explored,  cutting  down 
layer  by  layer,  until  it  is  ascertained  that  the  pleura  has  been  entered. 
Then  the  incision  is  extended  to  a  length  of  sLx  or  eight  inches  in  the 
wounded  interspace.  By  strong  retraction  of  the  ribs  (for  which  the 
rib-spreader  of  ^Mikulicz  is  convenient)  it  may  be  possible  to  complete 
the  operation  without  resecting  any  of  the  ribs.  Resection  of  one 
or  both  ribs  bordering  on  the  primary  incision  may  be  done  later  if 
necessary.  A  bleeding  intercostal  vessel,  which  may  be  the  only 
source  of  hemorrhage,  should  be  looked  for  and  ligated.  The  pleura 
having  been  widely  opened,  the  thoracic  cavity  is  tamponed  (by 
fine  silk  tampons  or  those  of  handkerchief  gauze  if  these  are  available), 
and  the  diaphragm  is  inspected,  unless  there  is  good  reason  to  believe 
that  it  has  not  been  injured.  If  a  wound  is  found,  it  should  be  treated 
as  described  at  p.  750.  If  bleeding  continues,  the  lung  is  caught 
in  volsellum  forceps,  and  is  drawn  into  the  thoracic  incision.  This 
fixes  the  mediastinum,  promotes  cardiac  action,  and  ventilates  the 
other  lung.  The  lung  is  then  searched  for  wounds,  and  these  are 
sutured  with  mattress  sutures  of  fine  chromic  gut,  introduced  close 
to  the  border  of  the  wound,  passed  deeply,  but  not  drawn  very  tight. 
Round-pointed  needles  should  be  used.  A  wound  of  exit  as  well 
as  one  of  entrance  should  be  looked  for.  If  the  wounds  cannot  be 
sutured,  they  should  be  packed;  or  a  very  extensive  wound  may  be 
"exteriorized"  by  suturing  its  margins  to  the  edges  of  the  parietal 
wound.  After  the  pulmonary  wound  has  been  sutured  the  lung 
will  expand  if  intratracheal  insufilation  is  being  employed,  and  the 
blood  which  has  collected  in  the  pleural  cavity  will  be  forced  out  of 
the  thoracic  incision.  If  it  is  not,  the  pleura  should  be  wiped  dry. 
No  irrigation  should  be  employed.  The  parietal  wound  is  then  closed 
in  layers  (pleura,  intercostal  muscles,  and  skin),  icithoid  drainage. 
If  the  anesthetic  has  been  administered  in  the  usual  way  it  will  be 
safer  to  leave  a  drainage  tube  in  the  incision  for  a  few  days;  this 
should  be  just  long  enough  to  enter  the  pleura.  In  22  cases  where 
the  wound  was  closed  without  drainage,  subsequent  drainage  for 
empyema  or  abscess  was  required  in  only  13  (Stuckey);  the  other 
9  patients  recovered  without  any  complication,  and  if  all  had  been 
drained,  all  would  have  had  empyema. 

Hernia  of  the  Lung  is  rare.  When  congenital  it  may  be  due  to 
defect  in  the  chest  wall,  or  may  develop  at  the  root  of  the  neck. 
Acquired  cases  usually  follow  some  months  or  years  after  injury  of 
the  thorax,  the  lung  bulging  out  beneath  the  cicatrix.  The  swelling 
is  sponge-like  in  consistency,  crepitates  on  pressure,  and  is  reducible; 


HEMOTHORAX  737 

it  increases  in  size  (iuriiij^  forced  expiration,  may  disappear  spon- 
taneously during  inspiration,  and  gives  an  impulse  on  coughing. 

Treatment.-  Treatment  seldom  is  required.  If  support  by  pads  or 
adlit'sixc  plaster  does  not  secure  relief,  an  operation  may  he  under- 
taken, dissecting  out  the  cicatrix,  and  repairing  the  wound  hy  over- 
lapping its  edges  in  several  layers.  The  pleural  cavity  need  not  be 
opened. 

Pneumothorax.  —  The  presence  of  air  in  the  pleural  cavity  as  a 
complication  of  injuries  of  the  thorax  has  been  alluded  to.  Occa- 
sionally the  condition  arises  from  disease  of  the  lung,  usually  tul)er- 
culous;  but  such  cases  have  little  surgical  importance.  The  pneumo- 
thorax may  be  open  or  closed:  that  is,  there  may  or  may  not  be  a 
wound  of  the  thoracic  parietes  producing  a  communication  between 
the  pleura  and  the  outer  atmosi)here.  If  there  is  no  external  wound 
(when  the  pneumothorax  is  due  to  escape  of  air  from  the  wounded 
or  diseased  lung),  or  if  the  thoracic  wound  is  small  or  valvular,  the 
pressure  of  the  air  in  the  pleura  may  be  increased  at  each  respiration, 
and  a  "tension  pneumothorax"  is  said  to  exist. 

Symptoms. — The  symptoms  depend  upon  the  rapidity  with  which 
the  pneumothorax  develops,  and  on  the  air  pressure.  A  very  suddenly 
produced  pneumothorax  may  cause  immediate  death  from  distortion 
of  the  mediastinum,  and  interference  with  the  action  of  the  heart  or 
the  other  lung.  One  of  very  slow  onset  may  produce  no  appreciable 
symptoms.  When  traumatic  in  origin,  the  symptoms  often  are 
obscured  by  those  of  shock,  internal  hemorrhage,  etc.  Unless  the 
lung  is  bound  down  by  adhesions,  the  air  fills  the  entire  pleural  cavity, 
and  the  entire  side  of  the  chest  affected  becomes  tympanitic  on 
percussion.  There  is  absence  of  respiratory  movements,  no  breath 
sounds  are  heard,  and  vocal  fremitus  is  absent.  If  the  air  is  under 
extremely  high  pressure  a  dull  note  may  be  obtained  on  percussion; 
this  is  rare.  Almost  always  there  is  dyspnea;  there  may  be  cyanosis; 
the  cardiac  action  may  be  embarrassed,  and  the  pulse  usually  is  weak, 
not  very  rapid,  and  may  be  irregular. 

Treatment. — In  most  cases  of  closed  imeumotJiorax  the  air  will  be 
absorbed  spontaneously  within  a  few  days,  and  no  treatment  is 
required.  If  dyspnea  is  severe  the  air  may  be  aspirated.  For  this 
a  very  fine  needle  should  be  used,  so  as  not  to  produce  subcutaneous 
emphysema.  In  cases  of  o])en  pneumothorax  relief  of  symptoms 
usually  follows  closure  of  the  external  wound  by  suture  or  occlusive 
dressing.  This  restores  the  piston  action  of  the  diaphragm,  ventilates 
the  other  lung,  and  facilitates  heart  action.  If  for  any  reason  the 
wound  cannot  be  closed,  and  the  symptoms  of  a  tension  pneumothorax 
supervene,  it  is  better  to  enlarge  the  parietal  wound  or  to  introduce 
a  drainage  tube,  thus  reducing  the  intraplem-al  pressure  to  that  of 
one  atmosphere. 

Hemothorax. — Blood  in  the  pleural  cavity  almost  invariably  is 
the  result  of  injury  to  the  thorax,  either  subcutaneous  or  penetrat- 
ing. The  hemorrhage  may  be  derived  from  the  lung  or  from  the 
47 


738  SURGERY  OF  THE  LUNGS  AND  PLEURA 

internal  mammary  or  one  of  the  intercostal  vessels.  Bleeding  from 
parietal  vessels  is  not  likely  to  stop  of  its  own  accord,  owing  to  the 
negati\'e  pressure  within  the  pleural  ca^aty.  If  the  bleeding  comes 
from  the  lung  it  will  not  cease  until  the  intrapleural  pressure  equals 
the  blood-pressure  within  the  lung;  but  as  this  is  only  one-third  as 
great  as  that  in  the  systemic  circulation,  intrapleural  hemorrhage 
from  a  lung  wound  will  stop  of  itself  much  sooner  than  will  bleeding 
from  an  intercostal  artery. 

The  physical  signs  are  those  of  pleural  effusion.  The  symptoms  of 
internal  hemorrhage  iuflicate  the  nature  of  the  effusion,  and  this 
may  be  proved  by  as])iration.  The  blood  does  not  clot  very  readily, 
and  forms  an  excellent  cidture  medium  for  bacteria.  Hence  there  is 
great  danger  of  secondary  empyema.  If  infection  does  not  occur, 
and  the  blood  finally  clots  and  becomes  organized,  extensive  and 
perhaps  disabling  pleural  adhesions  may  develop.  I  have  operated 
on  a  patient  with  calcification  of  the  entire  pleura,  the  result  of 
injury  many  years  previously. 

Treatment. — This  depends  upon  the  rapidity  of  the  hemorrhage  as 
well  as  upon  its  extent.  Rapid  bleeding  (indicated  by  the  symptoms 
of  internal  hemorrhage  and  by  rapid  increase  in  the  amoinit  of  fluid 
in  the  pleura)  usually  indicates  an  extensive  pulmonary  lesion,  and 
demands  operation,  as  described  under  stab  wounds  of  the  lung 
(p.  736).  If  the  bleeding  is  slower,  it  is  better  not  to  interfere  unless 
the  upper  level  of  the  dulness  (in  the  sitting  posture)  ascends  as  high 
as  the  spine  of  the  scapula,  or  unless  the  symptoms  of  hemorrhage 
are  very  pronounced. 

Pneumc-hemothorax. — Pneumo-hemothorax  is  more  frequent  than 
either  pneumothorax  or  hemothorax  separately.  The  air  rises  to  the 
upper  part  of  the  pleural  cavity,  and  the  blood  gradually  accumulates 
below.  The  physical  signs  are  those  of  pyo-])neum()thorax,  which 
are  described  in  every  text-book  of  general  medicine.  The  diagnosis 
depends  on  a  recognition  of  these,  and  on  a  history  of  recent  injury 
and  on  the  symptoms  of  internal  hemorrhage.  Aspiration  of  the 
fluid  pro\'es  its  hemorrhagic  nature.  Differentiation  from  diaphrag- 
matic hernia  (p.  751)  may  be  difficult.  Treatment  has  been  discussed 
sufficiently  under  the  separate  headings  pneumothorax  and  hemo- 
thorax. 

Chylothorax. — Chylothorax  usually  is  due  to  rupture  of  the  thoracic 
duct,  which  may  occur  as  a  complication  in  some  cases  of  fracture  of 
the  spine.  The  effusion  is  left-sided,  but  owing  to  more  serious  injuries 
often  is  overlooked.  Rapid  emaciation  is  characteristic,  but  the 
diagnosis  cannot  be  certain  until  some  of  the  fluid  has  been  withdrawn 
by  aspiration;  and  microscopical  and  perhaps  chemical  stiuiy  may  be 
necessary  then  to  determine  its  nature,  as  an  effusion  similar  in 
macroscopical  appearances  sometimes  occurs  in  cases  of  malignant 
disease  of  the  pleura.  Treatment  is  unsatisfactory.  In  some  cases 
repeated  aspiration  has  been  followed  by  recovery. 


I'YO'rilOh'AX,   OU   KMI'YKMA    TIJOh'AClS  ToO 

Hydrothorax.  llydiolliorax  is  tlio  lonu  used  to  »k'scril)('  a  collec- 
tion of  noii-iiiHammatory  fluid  (transudate)  in  the  pleural  cavity.  It 
presents  little  suru'ical  interest. 

Pleurisy  or  Pleuritis  is  an  inHunHiuition  of  the  pleura,  almost 
iu\arial)ly  of  bacterial  origin,  and  in  the  vast  majority  of  cases  due  to 
infection  transmitted  from  the  lung.  It  may  result  from  hematogen- 
ous infection,  but  this  is  rare.  It  is  always  present  in  some  degree 
in  cases  of  ])enetrating  wounds  of  the  thorax.  In  the  early  .stages  of 
the  inflanunation  a  plastic  exudate  is  formed,  and  if  the  ])rocess  stops 
here,  recovery  with  more  or  less  extensive  pleural  adhesions  may 
occur.  Such  cases  form  about  one-fifth  of  the  total  cases  of  pleurisy 
(Fraley,  11)07)  and  seldom  come  under  surgical  care.  In  about  three- 
fifths  of  ( ases  serous  eft'usion  occurs,  and  in  about  one-fifth  more  this 
eti'usion  finally  becomes  i)urulent  (pyo-thorax).  If  adhesions  have 
formed  early,  or  in  a  previous  attack  of  pleurisy,  the  effusion  may  be 
encapsulated;  its  site  then  may  be  between  the  lung  and  the  parietal 
pleura,  between  two  lobes  of  the  lung,  or  between  the  lung  and  dia- 
])hragm.  In  cases  where  there  are  no  adhesions  the  fluid  lies  free  in 
the  pleural  cavity  and  forces  the  lung  upward  and  backward  into  the 
spinal  gutter.  The  symptoms  of  pleurisy  with  effusion  are  detailed 
in  every  text-book  on  general  medicine,  and  need  not  be  recounted 
here.  The  diagnosis  is  confirmed  by  exploratory  puncture  with  an 
aspirating  syringe. 

Treatment. — If  the  eiTusion  is  large  and  if  no  tendency  to  reabsorp- 
tion  is  manifested,  and  particularly  if  the  constitutional  .symptoms 
indicate  suppuration,  the  fluid  should  be  aspirated,  as  described  at 
p.  147.  The  needle  is  passed  close  to  the  upper  border  of  the  rib, 
in  the  sixth,  seventh,  or  eighth  interspace,  usually  in  the  posterior 
axillary  line  or  below  the  angle  of  the  scapula.  The  site  may  be 
anesthetized  by  a  hypodermic  injection  of  cocain  or  by  ethyl  chloride 
spray.  Seldom  is  it  necessary  to  withdraw  all  the  fluid,  as  the  relief 
of  tension  secured  by  aspiration  of  a  portion  may  hasten  absorption 
of  the  remainder. 

Pyothorax,  or  Empyema  Thoracis,  is  a  collection  of  pus  within 
the  pleural  cavity.  It  is  the  suppurative  stage  of  pleurisy  with 
effusion;  but  in  many  cases  suppuration  occurs  so  rapidly  that  no 
anterior  stage  of  serous  effusion  can  be  recognized.  In  no  case  is 
there  any  sharp  line  of  distinction  to  be  drawn  between  the  two 
conditions,  as  the  serous  exudate  (when  one  exists)  gradually  becomes 
sero-purulent,  and  this  in  turn  assumes  the  usual  character  of  pus. 
The  pus  may  sink  to  the  bottom  of  the  pleural  cavity  as  a  heavy 
flocculent  sediment,  and  the  supernatant  liquid  may  remain  com- 
paratively clear. 

Pyothorax  is  most  frequent  in  children,  especially  as  a  complication 
or  result  of  croupous  pneumonia,  the  infecting  organism  being  the 
pneumococcus.  Pneumonia  if  followed  by  empyema  in  from  5  to  10 
per  cent,  of  cases.  In  adults  men  are  affected  much  oftener  than 
women,  and  the  empyema  results  less  often  from  a  frank  pneumonia; 


'40 


SURGERY  OF  THE  LUNGS  AXD  PLEURA 


in  many  cases  the  staphylococcus  or  streptococcus  is  the  infecting 
organism,  and  these  may  appear  as  secondary  infections  in  cases 
originally  caused  by  the  pneumococcus,  which  is  a  short-lived  organism. 
Unless  the  pus  is  evacuated  early,  the  parietal  and  visceral  pleurae 
become  thickened,  and  a  fixed  cavity  is  produced,  which  will  hinder 
expansion  of  the  lung  even  when  the  contained  fluid  has  been  removed. 
Adhesions  may  also  occur,  within  the  pleura,  and  much  oftener  than 
in  cases  of  serous  effusion  the  empyema  is  encapsulaied  either  on  the 
surface  of  the  lung,  between  its  lobes,  or  between  the  lung  and  dia- 
phragm.    In  rare  cases  the  pus  may  evacuate  itself  through  one  of 

the  bronchial  tubes,  or  may  per- 
forate the  diaphragm  and  form  a 
subphrenic  abscess.  In  children  it 
is  not  unusual  for  a  neglected 
empyema  to  break  through  an  in- 
tercostal space  and  to  point  sub- 
cutaneously.  In  adults  this  is 
rare  (Fig.  758).  This  condition  is 
described  as  an  empyema  neces- 
sitatis. If  the  empyema  ruptures 
externally,  which  is  very  unusual, 
a  pleural  fistula  is  left,  and  this 
scarcely  ever  heals  spontane- 
ously. 

Ssnnptoms  and  Diagnosis. — Usu- 
ally the  empyema  is  secondary  to 
some  thoracic  condition  (pneu- 
monia, bronchitis,  injury)  for  which 
the  patient  has  been  under  treat- 
ment. In  children,  in  whom  the 
condition  is  most  frequent,  an 
empyema  very  frequently  is  mis- 
taken for  an  unresolved  pneu- 
monia; but  this  condition  is  rare 
in  children,  and  if  an  aspirating 
s\Tinge  is  used,  as  it  should  be, 
for  exploration  in  such  cases,  the  diagnosis  will  be  quickly  cleared  up. 
The  physical  signs  in  children  may  be  very  misleading,  as  the  breath 
sounds  may  be  quite  clearly  heard;  this,  with  the  persisting  dulness 
on  percussion,  causes  the  resemblance  to  unresolved  pneumonia. 
There  may  be  Skodaic  resonance  above  the  dull  area.  But  tactile 
fremitus  is  decreased,  and  the  mere  fact  of  a  lingering  pneumonia 
in  a  child  should  make  one  suspect  an  empyema.  Xor  should  failure 
to  draw  pus  at  the  first  puncture  make  the  physician  conclude  that 
it  is  absent,  if  the  constitutional  signs  of  sepsis  persist.  The  pus 
may  be  too  thick  to  run  through  the  needle  employed,  or  the  collection 
may  be  encapsulated,  and  may  not  have  been  reached  by  the  needle. 
In  advanced  cases,  however,  the  diagnosis  is  easy;  the  temperature 


Fig.  75&. — Empyema  necessitatis, 
pointing  beneath  left  pectoral  muscles. 
Age  thirtj--two  years ;  phthisis  for  two 
j'ears:  pneumonia  seven  months  ago. 
"Abscess  in  thorax"  for  five  weeks. 
(Dr.  Harte's  case.)  Pennsylvania 
Hospital. 


PYOTHORAX,  OR  EMPYEMA    THORACIS 


741 


contimu's  ok'Nutcd,  and  thoiifili  remissions  may  occur  daily  or  oftener, 
the  normal  is  not  rtniclied.  The  apex  beat  of  the  heart  may  be  dis- 
placed l)y  laro;e  otVusions;  the  intorsi)aces  of  the  affected  side  may 
bnl^e;  (Hlated  veins  may  cover  tliis  side  of  the  thorax;  and  it  may 
seem  iarfjjer  than  the  heahhy  side,  though  its  resj)irat()ry  excursions 
are  less  than  normal  or  absent  (Fig.  759).  In  adults  the  diagnosis  of 
pleural  effusion  does  not  present  the  same  difficulties,  but  the  presence 
of  pus  rarely  can  be  asserted  positively  unless  j)aracentesis  is  done. 

Treatment. — A  child  almost  in  articiilo  moriis  may  be  saved  by 
prompt  evacuation  of  the  pus,  but  the  evacuation  should  not  be 
too  rapid  in  any  case  where 
there  is  marked  dysjjnea,  cya- 
nosis, etc.,  as  abrupt  change 
in  the  intrapleural  pressure 
may  cause  sudden  death.  In 
any  case  of  massive  effusion 
(one  extending  as  high  as  the 
spine  of  the  scapula)  it  is 
well  to  withdraw  half  or 
three-fourths  of  the  fluid  by 
aspiration  before  proceeding 
to  drain  the  chest. 

Murphy's  Method.  —  Mur- 
phy aspirates  the  pus  and  at 
once  injects  two  or  three 
ounces  of  a  2  per  cent,  solu- 
tion of  Liquor  Formaldehydi 
(U.  S.  P.)  in  glycerin.  This 
solution  should  have  been 
made  up  at  least  twenty-four 
hours  previously,  so  as  to 
allow  it  to  become  thoroughly 
mixed  and  sterile.  A  week 
later  the  fluid  is  aspirated 
again,  and  it  is  found  less 
purulent   and    more    serous; 

another  injection  of  the  formalin-glycerin  solution  is  given,  and  at  the 
third  or  fourth  aspiration  the  fluid  is  found  to  be  pure  serum.  This 
fluid  is  allowed  to  remain  in  the  pleural  cavity,  and  is  very  gradually 
absorbed,  as  the  lung  expands  and  the  chest  wall  sinks  in.  A  year 
or  more  may  elapse  before  all  the  fluid  is  absorbed,  but  as  it  is  sterile 
the  patient  is  in  no  way  inconvenienced  by  its  presence. 

Few  other  surgeons  have  adopted  Murphy's  plan  of  treatment, 
most  preferring  still  to  open  the  pleural  cavity  and  drain  the  abscess. 
Naturally  the  earlier  Murphy's  method  is  employed,  the  more  success- 
ful it  will  be;  if  employed  as  soon  as  the  first  evidences  of  suppuration 
appear  in  a  pleural  effusion,  one  injection  may  suffice  for  a  cure. 
But  in  cases  of  long  standing,  where  the  pleura  is  much  thickened 


Fig.  759. — Pyothorax  on  the  left,  following 
pneumonia.  Age  seven  years;  duration  two 
weeks.  Note  x  on  apex  beat,  displaced  to 
right;  dyspneic  expression;  bulging  of  left 
intercostal  spaces,  and  well  marked  intercostal 
depressions  on  right.     Children's  Hospital. 


742  SURGERY  OF  THE  LUNGS  AND  PLEURA 

and  the  limir  is  hound  down  by  adhesions,  I  think  tlioracotoniy,  as 
(U'scrihed  below,  is  to  be  preferred. 

Thoracotomy  or  Plevrotomy. — This  is  the  oi)eration  of  opening  the 
thoracic  cavity  for  the  purpose  of  draining  an  enii)yeina;  a  ])()rti()n 
of  a  rib  is  excised  to  ensure  free  drainage  (Konig,  1878).  The  rib 
selected  depends  on  the  location  of  the  pus,  if  this  is  encapsulated ; 
if  the  pus  is  free  in  the  pleural  cavity  the  surgeon  chooses  the  sixth 
rib  in  the  anterior  axillary  line,  the  seventh  in  the  mid-axillary  line, 
or  the  eighth  rib  in  the  posterior  axillary  line.  It  is  said  that  if  a 
lower  rib  is  chosen,  the  ascent  of  the  diaphragm  may  interfere  with 
drainage;  and  if  too  high  a  rib  is  selected  it  may  be  above  the  level 
of  the  pus,  and  the  lung  may  be  injured.  T.  T.  Thomas  (1913) 
advocates  resection  of  the  eleventh  rib  close  to  the  angle  to  secure 
dependent  drainage,  and  secure  prompt  closure  of  the  sinus.  In 
children  some  surgeons  prefer  an  intercostal  incision,  without  resec- 
tion of  a  rib,  but  I  believe  even  in  these  cases  convalescence  is  more 
rapid  if  a  larger  opening  is  made. 

The  operation  may  be  done  under  local  anesthesia  if  necessary: 
after  anesthetizing  the  skin  and  subcutaneous  tissues  as  usual,  the 
needle  is  inserted  in  the  intercostal  space  at  the  dorsal  extremity  of 
the  proposed  incision,  and  is  pushed  in  until  it  strikes  the  rib,  its 
point  is  then  manipulated  until  the  lower  border  of  the  rib  is  found, 
whereupon  it  passes  through  the  elastic  resistance  offered  by  the 
external  intercostal  muscle;  it  is  then  pushed  still  a  little  further  in, 
and  about  2  c.c.  of  a  1  per  cent,  solution  of  cocain  are  injected  around 
the  intercostal  nerve.  This  procedure  is  repeated  in  the  interspace 
next  below^;  and  after  a  few  minutes  the  intervening  rib  may  be 
painlessh^  resected.  In  many  cases,  especially  in  children,  a  general 
anesthetic  (ether)  is  to  be  preferred.  Dyspnea  should  be  relieved 
by  aspirating  most  of  the  pus  l)efore  beginning  the  operation.  The 
patient  is  not  to  be  turned  o\'er  on  the  healthy  side,  as  this  may  cause 
arrest  of  respiration  or  cardiac  action.  By  bringing  the  body  well 
over  the  side  of  the  table  the  operation  may  be  done  without  much 
difficulty,  as  the  patient  lies  supine.  Of  late  I  have  always  followed 
Elsberg's  suggestion  to  have  the  patient  lie  prone;  respiration  is 
perfectly  easy  in  this  position  and  the  operative  pneumothorax 
causes  less  pulmonary  collapse  than  in  the  usual  position. 

An  incision  of  about  tliree  inches  is  made  along  the  rib  selected, 
and  the  knife  is  carried  directly  down  to  the  bone.  Bleeding-points 
are  clamped.  The  periosteum  is  incised  and  is  stripped  from  the 
outer  surface  of  the  rib  throughout  the  length  of  the  incision,  by  means 
of  a  periosteal  elevator.  On  the  upper  surface  of  the  rib  strip  the 
periosteum  from  behind  forward,  and  on  the  inferior  surface  strip 
it  from  before  backward.  Then  the  periosteum  is  also  stripped  from 
the  deep  (pleural)  surface  of  the  rib,  keeping  the  instrument  close 
to  the  })one.  By  this  means  the  intercostal  ^'essels,  which  are  separated 
from  the  rib  by  its  periosteum,  are  pushed  aside  with  the  soft  parts. 
When  the  rib  has  been  thus  denuded  throughout  its  entire  circumfer- 


I'YOTIIOUAX,   Oh'   EMPYEMA    TIIOUACIS 


'AW 


Fig.  760. — Excision  of  a  rib  for  empyema. 


eiK-e  for  a  distaiur  of  about  two  iiiclics,  a  boiu'-cuttiiiK  forcrps  or  a 
special  costotoinc  i.s  used  to  divide  the  rib  at  one  end  of  the  incision. 
The  portion  of  rib  to  l)e  excised  is  tlien  <rrasi)ed  in  forceps,  and  the 
rib  is  (li\i(icd  at  the  other  end  of  the  incision  (Fig.  7()()),  and  the 
intervening  portion  is  removed.  Tliis  siiould  l)e  at  least  an  inch  and 
a  half  long.  The  parietal  i)leura,  still  covered  by  the  deep  layer  of 
the  ])eriosteuni,  then  presents  in 
the  wound;  these  structures 
shoukl  be  divided  in  the  axis 
of  the  rib  for  an  inch  or  more. 
In  some  cases  of  long  standing 
empy(Mna  the  i)arietal  pleura 
may  be  half  an  inch  thick. 
There  is  little  danger  of  wound- 
ing the  lung,  but  it  is  well  to 
take  the  same  ])recautions  as  in 
opening  the  peritoneum  (p.  821 ). 

The  intercostal  vessels  often  are  thrombosed,  and  may  not  bleed  if 
woimded ;  if  the  periosteum  has  been  stripped  carefully  from  the  rib 
before  this  is  excised,  and  if  the  deep  incision  is  made  nearer  the 
upper  than  the  lower,  border  of  the  rib,  these  vessels  will  not  })e 
wounded.  If  they  are  wounded,  bleeding  from  them  is  controlled 
more  easily  by  a  mass  suture  than  by  a  ligature. 

As  soon  as  the  pleura  is  opened  the  anesthetic  may  be  stopped. 
Usually  only  a  few  minutes  are  required  for  the  whole  operation. 
The  pus  should  be  allowed  to  escape  slowly.  Violent  paroxysms  of 
coughing  may  occur.  The  surgeon  should  introduce  his  finger  from 
time  to  time,  to  assist  the  discharge  of  masses  of  lymph.  If  the 
empyema  is  of  long  duration,  it  is  well  to  break  up  adhesions  between 
the  chest  wall  ancl  lung,  so  as  to  facilitate  its  subsequent  expansion. 
In  such  old  cases  the  infection  is  not  very  virulent,  and  septic  absorp- 
tion is  not  to  be  feared.  In  acute  cases,  where  the  infection  is  more 
active,  the  lung  is  not  firmly  bound  down,  and  its  release,  therefore, 
is  not  necessary. 

A  large  rubber  tube  (at  least  half  an  inch  in  diameter)  is  then 
passed  just  within  the  parietal  pleura,  and  is  fixed  by  a  stitch  to  the 
margin  of  the  skin  wound.  If  not  thus  fixed  it  may  fall  into  the 
pleural  cavity  or  be  pulled  out  of  the  wound  accidentally.  An  ex- 
tremely abundant  dressing  of  gauze  and  absorbent  cotton  is  applied, 
and  the  patient  is  returned  to  bed. 

After-treatment. — The  dressing  may  require  changing  several  times 
daily  at  first.  INIasses  of  lymph  blocking  the  tube  should  be  removed 
with  forceps.  No  irrigation  of  the  cavity  should  be  employed.  In 
some  instances  this  has  caused  death.  As  soon  as  agreeable  the 
patient  should  be  propped  up  in  bed,  and  measures  must  be  adopted 
to  promote  expansion  of  the  lung.  Every  time  the  clock  strikes 
the  hour  the  patient  should  be  instructed  to  take  a  half  dozen  or  more 
deep  respirations,  and  several  times  daily  he  should  blow  water  from 


744 


SURGERY  OF  THE  LUNGS  AND  PLEURA 


one  Wolff's  bottle  to  another  (Fig.  701).  Children  may  exercise  their 
lungs  by  blowing  up  toy  balloons,  sounding  trumpets,  etc.  Patients 
should  be  got  out  of  bed  as  soon  as  possible. 


Fig.  761. — Blowing  through  Wolff's  bottles  to  expand  lung  after  thoracotomy 
for  empyema.     Episcopal  Hosjjital. 

Convalescence  often  is  tedious,  and  may  be  interrupted  by  pneu- 
monic or  pleuritic  attacks,  with  evidences  of  septic  absorption. 
This  sometimes  is  due  to  interference  with  drainage  of  the  wound. 
In  favorable  cases  the  tube  does  not  require  to  be  replaced  when 
once  removed  at  the  expiration  of  ten  days  or  two  wrecks.  As  judged 
by  the  results  of  operation,  the  mortality  from  empyema  is  about 
20  to  25  per  cent.;  but  as  practically  all  patients  die  unless  operated 
on,  and  as  the  death  rate  from  the  primary  pneumonia  is  very  high, 
the  operation  must  be  regarded  as  a  distinct  life-saving  measure. 

Bilateral  Empyema. — Bilateral  empyema  is  most  frequent  in 
children.  Fabrikant  (1911)  has  collected  118  cases,  with  a  mortality 
of  37  per  cent.  The  second  side  should  be  operated  on  a  few  days 
after  the  first. 

Pleural  Fistula. — Pleural  fistula  may  persist  for  years  after  the  evac- 
uation of  an  empyema,  unless  properly  treated,  and  may  lead  to  death 
from  exhaustion,  amyloid  degeneration  of  the  viscera,  secondary 
tuberculosis,  or  some  intercurrent  disease.  If  the  emp}'ema  has  been 
recognized  early,  and  has  been  evacuated  promptly,  the  resulting 
sinus  closes  in  a  few  months  or  less.  It  is  in  cases  of  clironic  empyema, 
where  the  lung  is  bound  down  by  dense  adhesions,  that  a  large  thoracic 
cavity  remains.  From  this  a  pint  or  more  of  pus  may  be  discharged 
daily;  and  when  saprophytic  infection  is  added,  the  discharge  is 
exceedingly  putrid,  and  the  patient  is  loathsome  to  himself  and  to 
all  around  him.     The  thorax  becomes  deformed,  curvature  of  the 


PLEURAL  FfSTCLA 


745 


spine  develops  (Fig.  7(>2).  Ji'^d  the  i)iitient  is  ii  Iieij)less  cripple.  (  lul)- 
hing  of  the  fingers  is  frequent  (Fig.  494),  and  other  joint  changes 
may  add  to  his  misery  (pnhnonarN'  osteoarthroi)athy  (j).  47(5). 

Treatment.  Treatment  depends  npoii  the  extent  and  duration  of 
the  sinus.  A  small  and  recent  sinus,  which  does  not  discharge  \-ery 
much  pus,  often  may  he  made  to 
heal  hy  hisnuith  paste  injections 
(Ochsner,  11)09),  as  us(>d  for  tuber- 
culous sinuses  (j).  4S4).  This 
method,  with  skiagraphy,  is  valu- 
able in  determining  the  size  of  the 
cavity  within  the  thorax. 

When  there  is  much  purulent 
discharge  it  is  desirable  to  check 
this  before  instituting  any  formal 
oj)cration;  and  this  is  best  accom- 
plished l)y  irrigation  which  may 
be  employed  wnth  safety  in  these 
chronic  cases.  Potassium  perman- 
ganate solution  is  very  satisfactory. 
The  cavity  should  be  cleansed  at 
least  once  daily  in  this  manner. 

Sometimes  the  sinus  is  kept 
from  healing  by  the  presence  of  a 
drainage  tube  which  has  been  lost 
inside  the  wound.  This  may  be 
detected  by  a  skiagraph,  and  its 
removal  constitutes  the  first  step 
in    treatment. 

If  drainage  is  not  free,  tlie  sinus  should  be  enlarged,  under  an 
anesthetic,  and  the  surgeon  should  break  up  with  his  finger  the 
adhesions  between  the  lung  and  parietal  pleura;  and  if  the  cavity 
is  large,  he  should  resect  another  rib  at  its  most  dependent  portion, 
and  drain  from  the  lower  opening. 

Information  derived  from  use  of  the  a:-ray  may  be  an  aid  in  the 
prognosis:  if  the  collapsed  lung  is  permeable  to  air  the  a:-ray  will 
show  decreased  density  during  forced  expiration;  and  if  the  lung 
shows  a  tendency  to  expand  during  coughing,  it  is  probable  no  further 
operation  will  be  required  (Destot  and  Violet,  1904).  For  cases 
in  which  the  lung  is  permeable,  but  where  no  tendency  to  expansion 
is  apparent,  decortication  or  discission,  as  described  below,  should 
be  done.  If  the  lung  neither  shows  a  tendency  to  expand  nor  is 
permeable  to  air,  the  only  way  to  efface  the  pleural  cavity  is  to  resect 
the  bony  thoracic  cage  overlying  it,  and  thus  to  allow  the  soft  parts 
to  fall  in  against  the  lung  (Estlander,  Schede). 

Decortication  of  the  Lung  (Fowder,  Delorme,  1893). — This  consists 
in  opening  the  old  cavity  of  the  empyema  by  an  intercostal  incision 
or  the  resection  of  a  rib,  obtaining  sufficient  exposure  to  enable  the 


Fig.  762. — Scoliosis,  nine  months 
after  operation  for  empyema;  fistula 
still  discharges  eight  ounces  of  pus 
daily.    Episcopal  Hospital. 


74(i  SURGERY  OF   THE  LUNGS  AXD  PLEURA 

surgeon  to  explore  the  entire  interior  of  the  empyema  cavity.  The 
most  important  step  is  to  free  the  lung  thoroughly  from  its  attach- 
ments to  the  parietal  pleura.  This  is  best  done  by  making  an  incision 
through  the  latter  close  to  the  outer  or  posterior  margin  of  the  lung 
along  the  spinal  gutter.  The  fingers  are  then  inserted  between  the 
posterior  thoracic  wall  and  the  lung,  and  the  latter  is  gradually 
freed.  Its  natural  elasticity  and  tendency  to  expansion  aid  in  this 
manoeuvre.  When  the  lung  is  thus  freed  posteriorly  it  may  be  possible 
to  peel  the  remains  of  the  abscess  wall  off  its  surface.  The  thoracic 
wound  is  then  closed  with  drainage,  and  the  case  is  treated  as  one 
of  recent  empyema.  The  results  are  very  satisfactory,  the  lung 
expanding  and  the  abscess  cavity  becoming  obliterated. 

Discission  of  the  Pleura  (Ransohoff,  1903)  is  adopted  in  cases  where 
decortication  proves  difficult  or  impossible.  If  the  dense  membrane 
overlying  and  compressing  the  lung  is  scored  by  the  knife,  down  to 
the  lung  tissue  proper,  the  incision  will  gape  widely;  and  if  a  number 
of  such  incisions  are  made  in  parallel  and  criss-cross  lines,  each  inci- 
sion will  gape  so  widely  that  the  lung  will  expand  to  a  very  surprising 
degree. 

Thoracoplasty,  Estlander's  Operation  (1877). — This  consists  in  the 
resection  of  several  ribs  (three  to  five),  for  a  considerable  extent, 
directly  over  the  old  empyema  cavity,  in  order  to  allow  the  soft 
parts  of  the  thoracic  wall  to  fall  in  against  the  collapsed  and  non- 
expansile  lung.  The  cavity  is  thus  wholly  or  in  part  obliterated.  In 
very  large  cavities  the  operation  may  not  effect  a  cm-e,  but  the  result 
is  "the  difference  between  having  a  large  abscess  discharging  a  great 
quantity  of  pus,  and  a  small  sinus  which  weeps  a  little  thin  fluid." 
(J.  Ashhurst,  Jr.,  1894.)  The  operation  may  well  be  combined  with 
free  separation  of  the  lung  from  its  parietal  adhesions,  especially 
po.steriorly — a  modified  form  of  decortication.  Schede's  Operation 
(1890)  consists  in  resection  of  nearly  the  entire  bony  wall  of  the  side 
of  the  thorax  affected.  This  is  exposed  by  reflecting  an  immense  flap 
extending  from  the  second  costal  cartilage  anteriorly,  to  the  costal 
margin  below,  and  to  the  spine  of  the  scapula  posteriorly.  After 
removal  of  the  ribs,  this  flap  is  applied  against  the  exposed  lung. 
This  operation  has  a  high  mortality  and  is  rarely  done  at  the  present 
day,  when  earlier  and  more  thorough  treatment  of  the  acute  empyema 
enables  the  patients  to  recover  without  such  immense  cavities.  In 
no  cases  should  it  be  attempted  until  decortication  and  Estlander's 
operation  have  failed. 

Tuberculosis  of  the  Pleura,  usuaUy  secondary  to  that  of  the  lung 
or  bronchial  lymph  nodes,  presents  little  surgical  interest  except 
in  cases  with  effusion.  Most  painless,  slowly  developed,  and  appar- 
ently causeless  cases  of  pleural  effusion  in  adults  are  tuberculous. 
The  condition  is  recognized  by  the  physical  signs  of  pleural  eftusion, 
and  the  nature  of  the  fluid  may  be  suspected  from  the  patient's 
history.  Diagnostic  puncture  reveals  straw-colored  or  slightly 
turbid   fluid,  rarely   blood-tinged.    Tubercle   bacilli    seldom   can    be 


rrnKHciLosis  of  Tiih:  Lcxas  747 

(liscovcrcd,  l)Ut  a  liij^li  lym|)li()c\t(.'  coiiiit  iniiy.siijj;jft'st  the  tuberculous 
nature  of  the  Huid.  and  inoculation  experiments  usually  will  confirm 
the  diagnosis.  'Die  coiKJition  is  to  he  regarded  as  one  of  cold  abscess. 
Sect)ndary  infection,  from  the  ))erforation  of  a  tuberculous  cavity 
in  the  lung  into  the  pleura,  is  not  very  uncommon,  forming  a  pyo- 
pneumothorax. Secondary  infection  may  also  occur  through  the 
blood  or  from  the  unruptured  lung. 

Treatment.  Local  treatment  is  entirely  secondary  in  importance 
to  the  general  treatment  of  the  tuberculous  patient.  Only  if  the 
effusion  is  massive,  and  causes  dyspnea,  should  any  of  the  fluid  be 
withdrawn  by  aspiration.  If  much  fluid  is  withdrawn  (hufiage  may 
be  done  to  the  diseased  lung,  or  a  recently  closed  communication 
with  the  lung  may  be  reopened.  After  some  of  the  fluid  is  withdrawn 
the  remainder  may  be  gradually  absorbed.  If  on  aspiration  the  fluid 
is  found  to  be  verging  on  suppuration  (from  secondary  infection), 
an  ounce  or  two  of  formalin-glycerin  solution  (2  per  cent.),  should 
be  injected.  Under  no  circumstances  should  the  pleura  be  opened 
by  incision,  or  drainage  be  established:  such  a  course  surely  invites 
secondary  infection,  with  an  external  pyo-pneumothorax,  and  death 
usually  occurs  in  a  few  weeks.  Secundary  tuberculosis  in  an  open 
emjtyciua  ravifi/  may  occur,  but  is  not  so  quickly  fatal  as  a  primary 
tuberculous  pleurisy  secondarily  infected.  It  should  be  treated  as 
other  cases  of  open  pneumothorax  following  empyema,  with  special 
attention  to  the  patient's  general  health. 

Tuberculosis  of  the  Lungs. — Surgery  of  this  condition  may  be  said 
to  be  still  in  an  experimental  stage,  and  has  been  applied  mostly  to 
advanced  stages  of  the  disease  otherwise  incurable. 

In  1898  ]\Iurphy  introduced  to  surgical  notice  in  this  country,  a 
plan  of  treatment,  previously  advocated  (1882)  by  Forlanini,  con- 
sisting in  injections  of  nitrogen  gas  into  the  pleural  cavity,  to  cause 
collapse  of  the  lung  and  thus  to  induce  rest  and  promote  healing  of  the 
pulmonary  lesions.  Nitrogen  is  said  to  be  more  slowly  absorbed 
than  any  other  gaseous  substance.  Pneumonotomy,  to  drain  cavities 
in  the  lung,  has  been  done  on  numerous  occasions;  the  first  formal 
operation  is  the  historic  one  of  Baglivi  in  1643.  It  is  conceivable 
that  with  the  present  improvements  in  the  technique  of  pulmonary 
surgery  such  operation  may  find  a  legitimate  field  in  the  future  for 
the  rare  cases  in  which  an  apical  cavity  is  not  draining  well,  and  in 
which  no  other  discoverable  tuberculous  lesions  exist.  Partial  pneu- 
monecloniy  was  done  by  Tuffier  in  1891 ;  he  removed  the  apex  of  one 
lung,  containing  an  early  focus  of  tuberculosis.  The  patient  recovered 
and  was  in  good  health  four  years  later.  ^Medical  and  hygienic  treat- 
ment will  cure  such  patients,  and  no  operation  should  be  done.  Est- 
landers  Operation  was  suggested  in  1891  by  O.  H.  Allis  as  a  means 
by  which  collapse  of  a  pulmonary  cavity  might  be  secured,  with 
improved  chance  of  its  healing;  and  this  operation  has  been  employed 
by  Quincke  and  others.  Friedrich  (1909)  has  employed  Schede's 
method   for    the  purpose  of  causing  collapse  of  a  tuberculous  lung, 


748  SURGERY  OF  THE  LUNGS  AND  PLEURA 

the  other  hmg  being  lieahhy,  or  exhil)iting  no  evidence  of  active 
disease.  Freeman  (1909)  resected  the  upper  ribs,  and  after  the  wound 
had  liealed  adjusted  a  hernial  truss  over  the  apex  of  the  lung  to  cause 
obliteration  of  a  tuberculous  cavity.  Freund's  operation  of  chon- 
drectomy,  as  in  cases  of  pulmonary  emphysema,  has  also  been  employed 
in  cases  of  pulmonary  tuberculosis,  to  overcome  the  thoracic  rigidity 
which  prevents  aeration  of  the  lung.  Freund  in  1910  referred  to  8 
such  operations  in  patients  with  pulmonary  tuberculosis. 

Pulmonary  Emphysema. — W.  A.  Freund,  having  recognized  since 
1858  that  some  of  these  cases  are  caused  by  fixation  of  the  chest 
wall  due  to  ossification  of  the  chondral  cartilages,  proposed  in  1906, 
the  operation  of  chondreciomy  for  their  treatment.  The  costal  cartil- 
ages of  the  second,  third,  and  fourth  ribs  on  both  sides  of  the  thorax 
are  excised  with  their  perichondrium,  so  as  to  prevent  their  regenera- 
tion. The  operation  appears  to  have  been  employed  in  nearly  fifty 
cases,  with  a  fair  measure  of  success. 

Abscess  and  Gangrene  of  the  Lung,  which  are  not  very  frequent, 
may  be  regarded  as  different  stages  of  the  same  affection.  Most 
cases  occur  in  adults,  and  follow  pneumonia;  some  cases  follow  a 
pulmonary  infarct  from  a  septic  focus  elsewhere  in  the  body;  and 
some  follow  the  lodgement  of  foreign  bodies.  The  patients  usually  are 
in  a  very  poor  physical  condition,  with  degenerations  of  the  viscera, 
before  the  pulmonary  condition  develops. 

Symptoms. — Usually  these  develop  rather  suddenly  as  a  compli- 
cation of  the  preexisting  disease.  There  is  profound  sepsis.  Physical 
examination  reveals  a  localized  consolidation  in  the  lung,  which  may 
give  the  signs  of  cavity  after  expectoration  of  its  contained  sputum. 
The  sputum  from  an  abscess  is  great  in  quantity,  and  consists  of 
thick  yellow  pus,  not  malodorous  at  first.  The  older  the  abscess 
the  more  fetid  does  the  pus  become,  owning  to  saprophytic  infection. 
In  cases  of  gangrene,  which  usually  is  a  sequel  to  abscess  formation, 
this  fetid  character  of  the  pus  is  very  pronounced.  If  there  is  elastic 
tissue  in  the  sputum  it  is  not  probable  that  gangrene  is  present, 
since  saprophytic  bacteria  soon  destroy  it.  Pleurisy,  with  adhesions, 
frequently  occurs  and  may  prevent  perforation  of  the  abscess  into 
the  pleural  cavity  with  development  of  a  putrid  empyema.  The  use 
of  the  .T-ray  is  of  much  value  in  localizing  the  abscess.  If  exploratory 
puncture  is  done,  it  should  be  followed  at  once  by  operation. 

Treatment. — Operation  should  not  be  delayed  if  gangrene  is  pres- 
ent. The  patient  gets  no  stronger  by  waiting  even  for  one  day. 
Without  operation  80  per  cent,  of  cases  of  gangrene  of  the  lung 
die.  In  Korte's  28  operations  for  abscess  or  gangrene,  the  mor- 
tality was  28.5  per  cent.  (1909).  In  Lenhartz's  111  operations 
for  gangrene  the  mortality  varied  from  27  to  38  per  cent.  (1908). 
If  the  abscess  drains  well  through  a  bronchus,  operation  may  be  post- 
poned. Whenever  possible  the  operation  should  be  done  under  anes- 
thesia by  intratracheal  insufflation,  though  Korte  administered  the 
anesthetic  in  the  usual  wav.    The  ribs  overh'ing  the  site  of  the  abscess 


STAB  WOUNDS  OF  THE  DIAl'lUiAdM  749 

(whifh  should  ho  (IcttTinincd  het'orchaiidj  are  resected  suhperios- 
teally,  for  a  distance  of  three  or  four  inclies.  If  the  lung  is  not 
adhcTont  to  tlie  pleura  it  should  he  sutured  to  it  hy  interrupted 
mattress  sutures  of  chroniic  catpiut,  applied  in  a  circle  around  the 
supposed  site  t)f  the  abscess.  Soiuetinies  the  site  of  the  ahsccss  can 
be  detected  by  palpation,  being  denser  than  the  surrounding  lung 
tissue.  If  the  patient  is  not  in  very  serious  condition  the  second 
stage  of  the  operation  is  postponed  for  a  couple  of  days.  If  the  lung  is 
already  adherent  to  the  i)arietal  })lcura,  or  if  the  patient's  condition 
is  precarious,  the  surgeon  proceeds  at  once  to  open  the  lung.  This 
is  done  by  Hilton's  method,  first  thrusting  a  grooved  director  into 
the  lung,  and  when  pus  is  found  dilating  the  tract  with  dressing 
forcei)s.  Some  surgeons  use  the  actual  cautery  for  opening  the  abscess. 
Any  loose  necrotic  masses  of  lung  tissue  should  be  removed,  but  if 
even  lightly  adherent  they  should  not  be  disturbed  The  abscess  is 
drained  by  a  tube. 

Bronchiectasis. — For  this  condition  surgeons  do  an  operation 
similar  to  that  for  abscess  of  the  lung;  but  though  the  condition  is 
not  curable  by  medical  means,  the  cure  by  surgery  may  be  worse 
than  the  disease.  The  persistence  of  the  bronchiectatic  cavity  may 
not  materially  shorten  the  patient's  life,  and  the  risk  of  operation 
is  very  great.  In  Korte's  17  patients  the  mortality  of  the  operation 
was  73  per  cent. 

Tumors  of  the  Pleura  and  Lung  may  be  primary,  or  secondary 
to  growths  elsewhere.  Primary  growths  are  rare  and  very  difficult 
to  diagnose.  ]Most  of  them  are  malignant  in  nature.  Endothelioma 
and  sarcoma  occur  in  both  lung  and  pleura,  carcinoma  onlj'  in  the 
lung.  Tumors  of  the  pleura  invade  the  lung,  and  those  of  the  lung 
soon  attack  the  pleura.  Of  the  secondary  growths  carcinoma  is  more 
frequent  than  sarcoma. 

Symptoms. — The  symptoms  are  not  clearly  defined.  Some  cases  of 
primary  carcinoma  of  the  lung  are  mistaken  for  tuberculosis.  There 
is  dulness  on  percussion,  and  the  breath  sounds  are  absent  or  may  be 
heard  distantly.  Exploratory  puncture  may  reveal  a  bloody  pleural 
effusion,  or  there  may  be  a  dry  tap.  Blood  in  a  pleural  effusion  signi- 
fies either  tuberculosis  or  malignant  disease.  There  is  no  fever  and 
no  leukocytosis.  The  increase  in  the  physical  signs  is  rapid.  Cachexia 
appears  early  and  is  pronounced. 

Treatment. — There  is  little  to  do.  If  the  pleura  fills  with  fluid, 
and  this  causes  dyspnea,  thoracentesis  may  be  done.  A  few  cases 
of  excision  of  portions  of  the  lung  have  been  recorded,  the  patients 
surviving  the  operation  (Lenhartz). 

SURGERY  OF  THE  DIAPHRAGM. 

Stab  Wounds  of  the  Diaphragm. — In  the  majority  of  cases  the 
stab  wound  is  received  in  the  thorax,  by  a  downward  thrust,  and  a 
complicating  wound  of  the  pleura  exists.    This  is  almost  always  the 


750  SURGERY  OF   THE  DIAPHRAGM 

case  in  stal)  wounds  inflicted  by  Slavs,  but  Italians  frequently  stab 
their  antagonists  by  an  upward  thrust,  the  stiletto  entering  the 
abdomen  first.  The  left  side  is  more  often  injured  than  the  right. 
There  are  no  characteristic  symptoms,  and  the  diagnosis  can  be  made 
with  certainty  only  by  exploratory  operation,  except  in  the  rather 
unusual  cases  in  which  the  omentum  or  one  of  the  abdominal  ^'isce^a 
protrudes  through  the  thoracic  wound.  It  is  the  frequency  of  injury 
to  the  abdominal  contents  which  renders  these  wounds  so  serious. 
In  55  out  of  121  consecutive  stab  wounds  of  the  thorax,  recorded  by 
Lawrow  (1911),  the  diaphragm  and  abdominal  organs  were  in\'olved. 
The  wound  usually  is  in  one  of  the  lower  intercostal  spaces,  espe- 
cially between  the  seventh  and  tenth;  but  stab  wounds  as  high  as  the 
second  interspace  have  caused  injury  to  the  diaphragm.  The  liver 
is  the  most  frequently  injured  of  the  abdominal  viscera,  then  the 
stomach  or  spleen  (Magula,  1910). 

Treatment. — Treatment  is  by  immediate  exploratory  operation  in 
every  case  in  which  a  lesion  of  the  diaphragm  is  suspected.  The 
mortality  without  operation  is  nearly  90  per  cent.,  and  those  patients 
who  have  survived  the  immediate  injury  have  perished  eventually 
from  strangulation  of  a  diaphragmatic  hernia  or  other  lesion  which 
a  prompt  operation  could  have  prevented.  Thoracotomy  is  the  oper- 
ation of  choice,  because  by  laparotomy  it  is  \'ery  difficult  if  not  impos- 
sible (1)  to  reduce  the  herniated  organs,  owing  to  the  negative  pressure 
within  the  thorax,  (2)  to  repair  the  wound  of  the  diaphragm,  (.3)  to 
suture  wounds  of  the  cardia  or  fundus  of  the  stomach,  or  (4)  to  repair 
damage  to  the  lung.  The  technique  of  the  operation  is  much  the  same 
as  that  for  diaphragmatic  hernia  (p.  752).  If  the  stab  wound  is 
abdominal,  and  laparotomy  is  employed  as  the  primary  operation, 
secondary  thoracotomy  may  be  necessary  before  the  herniated  organs 
can  be  replaced  or  the  diapliragm  sutured;  such  an  operation  is 
described  as  thoraco-Japarotomy.  By  the  term  combined  operation 
is  understood  one  in  which  the  thoracic  and  abdominal  cavities  are 
opened  by  the  same  incision:  this  is  best  made  in  the  eighth  inter- 
space, dividing  the  ninth  costal  cartilage  and  the  diaphragm  as  far  as 
necessary  to  secure  free  exposure. 

If  the  case  is  not  complicated  by  injury  to  the  viscera,  the  mortality 
with  prompt  operation  is  less  than  20  per  cent.;  in  complicated  cases 
it  is  about  05  per  cent.  (Magula). 

Gunshot  Wounds  of  the  Diaphragm,  except  when  complicated  by 
injury  to  the  viscera,  are  so  rare  as  to  have  little  surgical  interest, 
unless  strangulation  of  a  hernia  occurs  subsequently  through  the 
opening  in  the  diapliragm.  In  most  cases  injuries  of  the  thoracic 
and  abdominal  organs  exist,  and  the  surgeon  has  to  employ  either 
thoraco-laparotomy  or  the  combined  operation. 

Rupture.  —  Rupture  of  the  diaphragm,  a  subcutaneous  injury,  is 
very  rare.  As  extensive  lesions  of  the  abdominal  organs  are  frequent, 
Deaver  and  Ashhurst  advise  laparotomy  as  the  primary  operation, 
so  that  hemorrhage  and  intestinal  leakage  may  be  controlled.     If 


DIAPHRAGMATIC  HERNIA  751 

it  is  (lilliciilt  to  reduce  tlie  organs  wliieii  lia\'e  l)eeii  iierniated  into  tlie 
thorax,  tiioracotomy  should  be  done  also;  this  usually  is  required  to 
t'aeilitat(>  repair  of  the  diaphragm. 

Diaphragmatic  Hernia  may  be  due  either  to  congenital  or  to  trau- 
matic defect  in  the  diaphragm.  Owing  to  the  negative  pressure 
within  the  thorax,  it  is  always  the  abdominal  organs  whieh  prolapse 
through  the  opening.  The  most  frequently  herniated  viseera  are 
the  stomach,  eolon,  omentum,  small  intestine,  liver,  duodemnn. 
and  kidney — in  the  order  named.  Though  a  congenital  defect  may 
be  present  at  birth,  the  hernia  may  not  appear  until  adult  Mfe.  and 
may  ])roduee  no  noteworthy  symptoms  until  strangulation  oecurs. 
In  owT  90  i)er  cent,  of  cases  the  hernia  is  on  the  left  side,  because  the 
liver  acts  as  a  protection  on  the  right.  ^Nlo.st  of  the  cases  occur  in 
the  fetus,  or  in  infants  stillborn  or  dying  soon  after  birth.  In  adult 
life  sudden  death  from  carrliac  failure  is  a  frequent  termination, 
and  the  possibility  of  a  diapliragmatic  hernia  always  should  be  re- 
membered in  considering  the  causes  of  sudden  death. 

Symptoms. — Subjecti^•e  symptoms  often  are  lacking,  the  malfor- 
mation being  found  unexpectedly  at  autopsy.  In  the  newborn, 
cyanosis  and  dyspnea  are  prominent,  the  left  thorax  does  not  expand 
properly,  there  is  dextrocardia,  and  death  usually  results  in  a  few 
hours.  The  adult  patient  may  have  suffered  from  mild  indigestion, 
with  distress  after  meals;  but  no  alarming  symptoms  may  arise  until 
sudden  cardiac  failure  or  perhaps  death  occurs  from  acute  over- 
distention  of  the  herniated  stomach.  Strangulation  is  a  frequent 
termination,  being  due  to  any  sudden  strain  which  forces  a  larger 
portion  of  the  abdominal  contents  through  the  diaphragmatic  opening. 

The  physical  signs  of  diaphragmatic  hernia  are  much  more  precise 
in  theory  than  in  practice.  Diagnosis  of  the  condition  in  life,  except 
by  the  aid  of  the  a;-ray,  is  exceptional.  The  lower  chest  on  the 
affected  side  is  tympanitic,  the  breath  soimds  are  very  feeble  and 
distant,  vocal  fremitus  is  lost,  expansion  is  decreased,  and  the  heart 
is  dislocated  away  from  the  affected  side.  The  same  signs  exist  in 
pneumothorax;  but  in  diaphragmatic  hernia  the  diaphragm  does 
not  descend  on  deep  inspiration,  and  causes  which  may  produce 
pneumothorax  nearly  always  may  be  absolutely  excluded.  ^Moreover, 
distention  of  the  stomach  with  liquid  will  change  the  physical  signs 
in  a  case  of  diapliragmatic  hernia;  but  in  pneumothorax  the  thoracic 
tympany  and  other  signs  will  not  be  affected.  Aspiration  is  to  be 
condemned  as  a  method  of  diagnosis,  owing  to  the  great  danger  of 
septic  pleuritis  or  peritonitis.  A  history  of  sudden  onset  following 
severe  strain  (sometimes  childbirth)  or  crushing  injury,  or  occurring 
some  years  after  a  stab  or  gunshot  wound  of  the  thorax,  is  higlily 
characteristic  of  diapliragmatic  hernia.  Finally  the  relation  of  the 
stomach  to  the  diaphragm  may  be  determined  by  the  use  of  skiagraphy 
after  filling  the  stomach  with  bismuth  emulsion  or  introducing  a 
stomach  tube  filled  with  mercury.  From  the  rare  or  congenital  con- 
dition known  as  eventration  of  the  diaphragm,  which  is  associated  with 


752  SURGERY  OF  THE  DIAPHRAGM 

hyperplasia  of  the  left  lung,  diapliragmatic  hernia  sometimes  may  be 
distinguished  by  the  history  of  the  case,  and  by  recognizing  through 
skiagraphy  that  the  diaphargm  in  the  former  condition  remains 
still  above  the  abdominal  organs  no  matter  how  far  upward  into  the 
thoracic  cavity  these  may  protrude. 

Treatment. — Immediate  operation  is  required  for  recent  diaphrag- 
matic hernia  of  sudden  development,  because  the  danger  of  strangu- 
lation is  very  great.  Unfortunately  most  such  cases  are  first  seen  by 
the  surgeon  after  strangulation  has  developed,  and  the  patient  is  too 
ill  to  justify  the  prolonged  examination  and  numerous  tests  recom- 
mended in  seeking  to  reach  a  correct  diagnosis.  But  if  the  surgeon 
can  ascertain  that  the  patient  has  had  a  severe  injury  (crush,  or  pene- 
trating wound  of  the  lower  thorax  or  upper  abdomen)  even  many 
years  previously,  the  diagnosis  and  indications  for  treatment  may 
become  very  apparent.  If  the  true  condition  is  recognized  thoracotomy 
(Permann  and  Postempski,  lSS9j  should  be  done.  In  many  cases  inci- 
sion in  the  eighth  intercostal  space,  without  resection  of  ribs,  has  given 
adequate  exposure.  After  packing  off  the  lung  with  fine  silk  or  hand- 
kerchief gauze  tampons,  any  rupture  or  perforation  of  the  abdominal 
viscera  should  be  repaired,  and  they  should  be  replaced  within  the 
abdominal  cavity.  Then  the  opening  in  the  diapliragm  should  be 
sutured;  when  this  is  not  possible  the  omentum  may  be  stitched  to 
its  margins,  or  as  a  last  resort  the  opening  may  be  tamponed.  If 
the  operation  has  been  done  under  difTerential  pressure  or  with 
intratracheal  insufflation  anesthesia,  the  pleura  may  be  closed  without 
drainage.     In  other  cases  a  tube  should  be  left  in  for  a  few  daj's. 

If  no  diagnosis  other  than  intestinal  obstruction  has  been  made, 
laparotomy  will  be  the  operation  employed;  but  if  reduction  of  the 
hernia  from  below  proves  impossible,  no  hesitation  should  be  fe't 
in  proceeding  to  thoracotomy. 


CHAl'TKJi    XXI. 
IIKKXIA. 

A  hernia  is  a  protrusion  of  a  viscus  through  an  abnormal  opening 
in  the  walls  of  the  cavity  within  which  it  is  naturally  contained.  This 
is  a  general  definition,  and  may  he  ai)plied  to  a  hernia  of  a  muscle 
through  a  rupture  in  its  sheath,  to  a  hernia  of  the  brain  through  an 
artificial  opening  in  the  skull,  or  to  a  hernia  of  an  abdominal  viscus 
through  an  abnormal  opening  in  the  abdominal  \valls.  By  long 
usage,  however,  the  term  hernia,  when  standing  by  itself,  is  applied 
only  to  protrusions  of  the  abdominal  viscera.  This  protrusion  usually 
occurs  through  an  aperture  of  the  abdominal  wall  which  transmits 
bloodvessels  or  nerves,  through  a  congenital  defect,  or  through  one 
acquired  as  the  result  of  operation  or  disease.  If  this  protrusion  occurs 
through  a  normal  opening  it  is  not  called  a  hernia,  but  a  prolapse; 
as  a  prolapse  of  the  rectum  through  the  anus,  or  of  the  uterus  through 
the  vagina.  The  term  hernia  also  implies  that  the  protruding  struc- 
tures are  still  Covered  by  skin:  thus  when  omentum  or  other  structure 
protrudes  through  an  incised  wound  of  the  abdomen,  it  is  not  called 
a  hernia  but  a  prolapse. 

In  the  great  majority  of  cases  of  abdominal  hernia,  the  viscus  which 
protrudes  carries  before  it  a  pouch  of  the  parietal  peritoneum,  which 
is  called  the  sac  of  the  hernia-;  and  since  this  sac  may  remain  as  a  pro- 
trusion even  when  it  contains  none  of  the  abdominal  viscera,  a  hernia 
has  been  defined  as  "a  protrusion  of  peritoneum  liable  to  contain, 
containing  at  times,  or  permanently  containing  any  viscus  or  part  of 
a  viscus  from  the  abdominal  cavity."  (Da  Costa.)  But  as  the  abdomi- 
nal organs  sometimes  protrude  through  a  part  of  the  abdominal  wall 
which  has  no  parietal  peritoneum  (e.  g.,  a  hernia  of  the  bladder),  or 
slide  down  behind  the  parietal  peritoneum,  instead  of  carrying  it  before 
them  as  a  protrusion  (e.  g.,  sliding  hernia  of  the  colon),  I  think  it  is 
better  to  cling  to  the  old  definition.  If  the  sac  protrudes  and  is 
empty  that  patient  has  either  a  reduced  or  a  potential  hernia,  accord- 
ing to  whether  or  not  the  sac  has  before  been  the  seat  of  a  hernia. 
A  sac  may  exist  for  many  vears  without  a  hernia  developing  in  it 
(p.  754). 

Nomenclature. — A  hernia  receives  its  name  (1)  from  the  region 
in  tvhich  it  appears,  as  epigastric,  lumbar,  umbilical,  inguinal,  etc.; 
(2)  from  its  contents,  as  a  hernia  of  intestine  (enterocele),  of  omentum 
(epiplocele),  of  bladder  (cystocele),  of  rectum  (rectocele),  etc.;  (3) 
from  its  condition,  as  reducible,  irreducible,  inflamed,  strangulated, 
etc.;  and  (4)  from  its  mode  of  development,  whether  of  sudden  develop- 
48 


754  HERNIA 

ment  or  slowly  acquired.  Various  other  terms,  used  in  describing 
hernia,  will  be  explained  as  they  are  encountered. 

Causes. — The  predisposing  causes  of  a  hernia  ma\'  be  either  general 
or   local. 

General  Predisposing  Causes. — (1)  Age.  Most  hernise  appear  in  infan- 
tile or  early  adult  life;  the  longer  one  lives  the  less  apt  he  is  to  have  a 
hernia.  But  the  number  of  old  people  alive  is  so  much  less  than  that 
of  young  adults  and  children,  that  among  the  aged  hernia  is  relatively 
more  common.  (2)  Sex.  ]\Ien  and  boys  are  much  oftener  afflicted 
with  hernia  than  women.  There  are  two  main  reasons  for  this:  first 
because  of  the  weakness  of  the  inguinal  region  in  the  male  sex  from 
the  descent  through  it  of  the  testicle;  and,  second,  from  the  more  active 
life  men  lead,  and  the  greater  frequency  with  which  they  are  sub- 
jected to  great  abdominal  strains.  (3)  A  distinct  hereditary  tendency 
toward  hernia  is  recognized,  probably  from  the  persistence  of  anatomi- 
cal defects  at  points  of  greatest  strain. 

Local  Predisposing  Causes. — (1)  Weakness  of  the  abdominal  wall. 
After  an  abdominal  operation,  a  hernia  may  develop  in  the  scar 
(incisional  hernia,  p.  772) :  or  as  a  consequence  of  injury  to  the  motor 
nerves  of  the  inguinal  region  from  an  operation  elsewhere,  an  inguinal 
hernia  subsequently  may  develop  (Figs.  774,  788,  and  792).  Some- 
times a  hernia  appears  first  after  a  debilitating  illness  or  pregnancy. 
(2)  Increased  strain  upon  the  yarietes  by  the  abdominal  contents.  The 
gradual  deposition  of  fat  in  the  omentum  and  mesentery  increases  the 
intra-abdominal  tension,  causes  stretching  of  the  parietal  peritoneum, 
opens  up  the  hernial  orifices,  and  thus  predisposes  to  the  development 
of  a  hernia.  The  same  train  of  events  may  occur  in  cases  of  ascites, 
of  intra-abdominal  tumors,  of  pregnancy,  etc.  (8)  A  hernia  may  be 
the  effect  of  repeated  efforts,  in  coughing,  in  straining  at  stool,  in  urinat- 
ing (when  there  is  some  urinary  obstruction)  (Fig.  798).  (4)  The 
existence  of  a  congenital  sac  predisposes  the  patient  to  the  develop- 
ment of  a  hernia,  though  observations  in  the  dissecting  room  show 
that  many  patients  with  preformed  sacs  pass  through  life  without 
any  evidence  of  a  hernia. 

Structures  Composing  a  Hernia. — In  a  typical  case  a  hernia  is 
composed  of  a  pouch  of  parietal  peritoneum,  called  the  sac;  of  the 
contents  of  the  sac;  and  of  its  coverings,  which  are  the  structures  of 
the  abdominal  wall,  muscles,  fascia,  and  skin  (Fig.  763). 

Sac. — The  sac,  as  noted  already,  sometimes  is  wholly  or  in  part 
deficient.  Typically  it  is  composed  of  a  neck  (that  part  which  com- 
municates with  the  peritoneal  cavity),  and  a  body  (that  part  which 
surrounds  the  protruding  viscera).  The  apex  of  the  sac  is  ']t<.  fundus. 
The  sac  may  })e  congenital  or  acquired.  I  believe,  with  Russell  and 
Murray,  that  the  sac  is  congenital  in  a  far  larger  proportion  of  cases 
than  is  commonly  thought.  This  preformed  sac  renders  the  patient 
the  potential  possessor  of  a  hernia;  but  until  the  hernia  develops 
("comes  down"  is  the  colloquial  expression),  the  i)resence  of  the  sac 
in  most  cases  cannot  be  determined  (p.  1058,  congenital  hydrocele). 


STRUCTURES  COMl'OSISC   A    IIKRMA 


755 


Perito/ifum 

.Transversalts  /irsaa 
Muscle 

. . .  Skin  i  Sup.  fascur. 


Fig.  763. — Diagram  to  show  a  hernial 
sac,  its  contents  and  coverings. 


The  c()H(/rnilal  .vac  is   fouud  oftciu'st  in  inj^uinal  liiTuia,  Ijut  occur.s 

frequently  also    in    the  femoral    form,  and  sometimes  in  umbilical 

hernia.    It  nia\'  he  \ery  lar<;e,  hut  usually  is  (juite  small  until  distended 

hy  the  protrudinji,'  ahdoniinal  contents.     The  arqnirrd  .sac  usually  is 

slowly  developed  from  gradual  stretching  of  the  parietal  peritoneum: 

at  first  the  neck  of  the  acquired  .sac  is  its  widest  part,  hut  as  the  sac 

increases  in  size  it  becomes  more 

or    less    pear-shajjcd,    the    neck 

being  relatively  narrow;  then  the 

sac  continues  to  increase  in  size 

by  the  pressure  of  the  contained 

.structures,  but,  as  a  rule,  the  neck 

does  not  enlarge  at  the  same  rate 

but  remains  relatively  small.  The 

wall  of  the  sac,  at  first  like  the 

neighboring  ])arietal  peritoneum 

may  become  much  thickened  from 

inflammation,  and  its  neck  may 

undergo    cicatricial    contraction. 

The  sac  usually  becomes  densely 

adherent  to  the  surrounding  parts, 

especially    at    its    fundus;    and 

though  the  contents   of  the  sac  may  be  returned  to  the  abdomen, 

as  long  as  the  empty  sac  remains  recurrence  of  the  hernia  is  to  be 

expected.    In  hernia  of  long   duration   the   neck  of  the  sac  may  be 

shifterl,  by  the  pull  of  its  contents,  downward  and  toward  the  median 

line  of  the  body. 

The  Contents  of  the  Sac  may  be  almost  any  of  the  abdominal 
viscera,  but  the  most  frequently  herniated  structures  are  the  intes- 
tine fenterocele),  and  the  omentum  (epiplocele).  In  infancy  and 
young  childhood  the  omentum  seldom  is  found  in  a  hernia,  owing 
to  its  undeveloped  state;  but  in  adults,  particularly  those  who 
are  obese,  it  is  the  most  frequently  found  of  all  structures.  The 
lower  ileum  is  the  portion  of  the  bowel  most  often  found  in  a 
hernia,  because  it  has  the  longest  mesentery  and  lies  nearest  the 
inguinal  and  femoral  openings.  Hernia  of  the  large  bowel  is  infre- 
quent, owing  to  its  relatively  short  mesenteric  attachments.  The 
cecum  may  be  drawn  into  a  hernia  by  a  coil  of  ileum  already  there; 
but  the  sigmoid  is  sufficiently  mobile  to  find  its  own  way  into  a  hernia. 
A  single  coil  or  several  coils  of  intestine  may  be  found  in  the  sac, 
or  the  hernia  may  be  formed  only  by  a  portion  of  the  wall  of  the  intes- 
tine; this  latter  condition  (Fig.  764)  is  described  as  Richters  hernia 
(1778).  A  hernia  of  ^Meckel's  diverticulum  (Fig.  7()5)  is  known  as 
Littres  hernia  (1700).  When  the  herniai  contents  remain  long  in  the 
sac,  they  usually  become  adherent  to  its  walls  and  often  are  matted 
together.  In  this  way  a  hernia  may  become  irreducible.  When  both 
omentum  and  intestine  are  in  the  sac  (entero-epiplocele),  it  usually  is 
the  omentum  which  enters  it  first.     The  omentum  generally  lies  in 


756 


HERNIA 


front  of,  or  even  completely  surrounds  the  bowel,  and  the  bowel  may 
be  caught  in  apertures  or  depressions  in  the  mass  of  omentum  and 
thus  may  become  strangulated.  Unless  the  hernia  is  inflamed  or 
strangulated  there  is  little  or  no  serum  within  the  sac. 


Fig.  764. — Partial  enterocele,  or  Richter's  hernia.     Drawing  made  from  a  caee 
of  strangulated  hernia  in  the  Episcopal  Hospital. 

The  Coverings  of  the  sac  \\  ill  be  described  in  connection  with  each 
particular  form  of  hernia. 


«|]»i 


Fig.  765. 


-Littre's  hernia — a  hernia  of  one  of  the  intestinal  diverticula 
(Meckel's  diverticulum). 


Reducible  Hernia. — This  is  one  in  which  the  contents  can  })e  replaced 
within  the  abdominal  cavity.  It  is  the  most  frequent  variety,  since 
almost  every  hernia  is  reducible  when  it  first  appears,  and  becomes 
irreducible  only  after  the  lapse  of  years.  For  months  or  years  before 
the  hernia  appears  the  patient  may  have  felt  a  weakness  in  the  region 
where  the  protrusion  afterward  develops.  If  the  hernia  develops 
gradually,  there  may  be  at  first  the  merest  bulging  of  the  parts  during 
straining  efforts;  later  a  small  rounded  tumor  may  be  seen.  This  can 
be  reduced  easily  by  the  pressure  of  a  finger,  and  usually  disappears 
spontaneously  when  the  patient  lies  down.  In  cases  of  hernia  prescjit 
at  birth,  or  of  sudden  though  later  development,  or  of  long  duratit)n 
before  seen  by  the  surgeon,  the  protrusion  often  is  of  considerable 


REDUCUiLE   IIF.RMA  ITu 

size.  In  time  tiie  greater  part  ol"  the  alxloiiiiiial  contents  may  descend 
into  the  sac. 

Tlie  ontline  of  a  liernia  is  more  or  less  ronnded  or  oval,  usually 
being  less  broad  at  the  neck  of  the  sac  than  elsewhere.  The  hernia 
increases  in  size  when  the  patient  stands  up,  coughs,  or  strains;  it 
disap})ears  either  spontaneously  or  by  gentle  pressure  when  he  lies 
down;  and  in  most  cases  it  reappears  again  if  he  once  more  stands 
up  and  coughs.  When  he  coughs  there  usually  is  a  distinct  impulse 
transmitted  to  the  hernia,  and  this  often  can  be  seen  and  almost 
always  can  be  felt. 

Enterocele. — If  the  sac  contains  intestine  only,  the  hernia  is  smooth, 
feels  elastic,  often  gurgles  on  palpation,  and  usually  is  resonant  on 
percussion.  The  impulse  is  well  marked.  Reduction  usually  is 
accompanied  by  a  distinct  gurgle  and  by  a  characteristic  sensation 
well  described  as  a  "flop." 

Epiplocele. — An  omental  hernia  feels  denser,  more  fibrous  or  doughy 
to  the  touch  than  an  intestinal  hernia;  it  is  irregular  in  outline;  gives 
little  or  no  impulse  on  coughing;  and  is  dull  on  percussion.  Reduction 
is  not  accompanied  by  any  gurgle,  nor  by  the  "flop"  so  characteristic 
of  bowel  slipping  back  into  the  abdomen. 

In  the  enter o-epiplocele  the  symptoms  of  the  two  separate  forms  are 
combined. 

It  seldom  is  possible  to  ascertain  what  portion  of  the  gut  forms  the 
hernia.  In  umbilical  hernia  the  transverse  colon  is  most  often  found; 
and  in  inguinal  and  femoral  hernia,  the  ileum.  The  cecum  is  much 
more  frequent  in  right-sided  inguinal  hernia  than  elsewhere,  but  is 
not  very  unusual  in  a  left  inguinal  hernia.  In  femoral  hernia  the 
omentum  and  small  bowel  are  most  often  found. 

Treatment. — It  is  necessary  for  a  hernia  to  be  cured,  whenever 
possible,  because  of  the  grave  danger  which  may  accrue  to  the  patient 
from  the  occurrence  of  strangulation.  A  cure  can  be  obtained  only 
by  an  operation,  by  which  the  sac  of  the  hernia  is  removed,  its  neck 
closed,  and  the  structures  of  the  abdominal  wall  repaired  in  such  a 
manner  as  to  prevent  recurrence  of  a  hernia.  This  is  the  best  treat- 
ment in  every  case  in  which  an  operation  is  not  contraindicated ; 
but  the  operation  requires  skill  for  its  performance,  and  sometimes 
is  very  difficult.  It  should  not  be  attempted  by  the  occasional  operator. 
Even  if  the  best  treatment  (that  which  results  in  cure)  is  contra- 
indicated  or  is  refused,  it  is  still  necessary  that  the  hernia  be  treated. 
An  untreated  hernia  tends  constantly  to  grow  larger  and  to  become 
irreducible.  It  is  possible  to  keep  a  hernia  reduced  by  the  use  of 
apparatus  (known  as  a  truss)  which  exerts  pressure  over  the  neck  of 
the  empty  sac,  and  prevents  descent  of  the  hernial  contents.^  It  used 
to  be  taught  that  in  some  cases  the  prolonged  use  of  a  truss  might 
cause  obliteration  of  the  hernial  orifice  by  exciting  adhesions  of  the 

1  I  mention  only  to  condemn  the  attempts  of  some  charlatans  to  cause  closure 
of  the  neck  of  the  hernial  sac  by  injecting  paraffin  in  the  surrounding  tissues 
(Fig.  766). 


75S 


HERNIA 


( )]>!)( )si  11  (if  layers  of  peritoneum.  This  oceasioiuilly  occurs  in  infants, 
hut  in  the  vast  majority  of  cases,  though  a  truss  may  keep  the  hernia 
reduced  so  long  as  the  truss  is  in  place,  no  obliteration  in  the  neck  of 
the  sac  is  caused,  and  its  contents  tend  to  return  at  once  when  the 
truss  is  removed.  If  the  neck  of  the  sac  becomes  constricted  from 
prolonged  use  of  a  truss  (and  this  is  not  unusual),  the  hernia  will  be 
more  apt  to  become  strangulated,  if  it  comes  down,  than  if  no  truss 

had  been  worn.  If  no  treat- 
ment at  all  is  undertaken,  the 
hernia  constantly  increases  in 
size,  is  very  apt  to  become 
irreducible,  and  the  patient 
must  endure  the  discomforts 
of  this  condition  as  well  as 
run  the  added  risk  of  stran- 
gulation w^hich  an  irreducible 
hernia  entails. 

The  contraindications  to 
operation  in  the  case  of  a 
reducible  hernia  are  only  those 
which  contraindicate  any 
operation,  however  trivial  (p. 
760).  There  are  no  local  con- 
ditions which  contraindicate 
operation  in  cases  of  reduci- 
ble hernia.  Even  immense 
size  of  the  hernial  orifice, 
with  excessively  weak  ab- 
dominal walls,  is  a  condition 
that  may  be  overcome  by 
proper  methods  (p.  774). 
K  truss  is  an  apparatus  designed  to  support  a  hernia.  It  should  keep 
a  reducible  hernia  reduced.  It  is  applied  around  the  body,  and  has  a 
pad  which  makes  pressure  over  the  hernial  orifice.  Most  trusses  are 
for  inguinal  or  femoral  hernia,  and  are  applied  around  the  pelvis 
between  the  iliac  crests  and  the  trochanters  of  the  femora  (Fig.  792). 
A  truss  may  be  made  of  steel  covered  with  leather  or  hard  rubber, 
causing  elastic  pressure  over  the  hernial  orifice;  or  it  may  be  made 
entirely  of  leather,  and  depend  on  the  tension  with  which  it  is  buckled 
in  place  to  retain  the  hernia.  Trusses  are  also  used  for  umbilical 
hernise;  and  the  abdominal  belts,  used  to  support  ventral  and  inci- 
sional hernia  may  be  considered  a  form  of  truss. 

There  are  certain  features  which  ever}-  truss  should  possess:  it 
should  retain  its  position  without  extraneous  aid;  it  should  keep  the 
hernia  reduced  in  all  positions  of  the  body,  and  during  coughing, 
sneezing,  defecation,  etc.;  it  should  not  cause  irritation  of  the  skin 
overlying  the  hernia  or  elsewhere;  and  it  should  be  easily  kept  clean. 
The  patient  must  have  at  least  two  trusses,  in  case  one  of  them  is 


Fi( 


AIa^~< 


)f    piirafiin    in    inguinal 


canal  and  scrotum,  injected  on  two  occasions, 
several  months  ago,  in  effort  to  cure  a  hernia 
of  twelve  years'  duration.  Patient  aged  thirtj'- 
eight  years.  Hernia  now  in  scrotum.  Epis- 
copal Hospital. 


lliRKDVCllilJ':  IIKUMA  7.V.) 

hrokoii.  I'lic  trusses  suital)lt'  tor  the  (liU'crciit  tonus  of  licniia  will 
he  described  under  special  licniia'  (p,  7.SG). 

Do  (larnio  says  a  jiatient  wlio  wears  a  truss  is  a  eiirouic  invalid, 
and  tlioufj;li  this  statement  is  somewhat  of  an  exaggeration,  it  is 
al)solutely  true  tluit  such  a  i)Htient  nuist  ()l)serve  certain  rules  of  con- 
duct if  he  wishes  to  continue  in  j^ood  healtli.  lie  sliould  he  kept  under 
his  pliysician's  ohserx  ation.  A  truss  requires  as  strict  oversight  as 
any  other  orthojjethc  ai)i)liance  (p.  517).  The  truss  must  always  he 
applied  while  the  i)atient  is  recumhent,  after  reduction  of  the  hernia; 
it  need  not  he  worn  at  night,  hut  it  should  he  reapplied  every  morning 
het'ore  the  patient  gets  out  of  hed.  It  must  never  he  taken  off  except 
w'hen  he  is  lying  down.  When  he  takes  a  hath  he  must  wear  the  truss 
in  the  tuh.  lie  must  not  make  any  sudden  exertion  or  strain  at  any 
time.  He  must  lift  no  heavy  weights.  He  must  not  go  swimming. 
He  should  he  debarred  from  all  athletics  except  the  lightest  exercises. 
If  he  wants  to  be  cured  of  his  hernia,  let  him  he  operated  on.  Other- 
wise he  must  endure  the  limitations  which  truss-wearing  requires. 
The  possibility  of  strangulation  of  his  hernia  should  he  ever  present 
in  his  mind.  Should  it  occur  it  will  force  him  almost  always  to  an 
immediate  operation  to  escape  death;  and  he  will  be  unable  to 
choose  either  the  time,  or  the  place,  or  the  surgeon  for  such  an 
operation. 

Irreducible  Hernia. — The  commonest  causes  for  irreducibility  of  a 
hernia  are  inflammatory  adhesions  affecting  its  contents.  These  may 
he  between  the  sac  and  its  contents,  or  adhesions  of  the  coils  of  bowel 
to  each  other,  to  the  omentum,  etc.  The  most  frequent  cause  is 
adhesion  of  the  omentum  to  the  sac.  The  bowel  rarely  becomes 
adherent  to  the  sac. 

Intravisceral  adhesions  often  prevent  reduction  even  when  no 
adhesions  to  the  sac  wall  exist,  because  the  contents  are  amal- 
gamated into  a  mass  too  large  to  pass  through  the  neck  of  the 
sac.  A  hernia  may  be  apparently  irreducible,  because  manipulation 
cannot  force  hack  in  a  short  time,  through  a  small  orifice,  a  large 
mass  of  intestines  or  omentum  which  have  taken  years  to  descend. 
There  is  no  strangulation  present  in  an  irreducible  hernia,  though  a 
strangulated  hernia  may  be  irreducible.  The  diagnosis  of  an  irre- 
ducible hernia  depends  upon  recognizing  that  the  protrusion  is  at  one 
of  the  usual  hernial  orifices,  on  ascertaining  tlie  history  of  its  develop- 
ment, and  on  the  physical  signs,  which  are  the  same  as  in  a  reducible 
hernia,  with  a  few^  self  evident  exceptions.  An  irreducible  hernia 
presents  an  impulse  on  coughing;  it  constantly  tends  to  become  larger, 
and  the  patient  suffers  from  a  sense  of  dragging,  from  digestive  dis- 
turbances, and  often  from  intermittent  attacks  of  constipation  and 
diarrhea.  Though  a  patient  may  live  for  many  years  with  an  irre- 
ducible hernia,  he  is  in  constant  peril  because  the  prolapsed  viscera 
are  exposed  to  trauma,  and  are  liable  to  repeated  attacks  of  inflam- 
mation or  obstruction;  and  strangulation  is  much  more  apt  to  occur 
than  in  the  case  of  a  hernia  which  is  retained  b^■  a  truss. 


7G0  HERNIA 

Treatment. — The  cure  of  an  irreducible  hernia  is  more  difficult  and 
dangerous  than  that  of  a  simple  hernia,  and  can  he  secured  only  by 
operation.  Except  in  the  very  old,  or  those  with  severe  constitutional 
or  organic  disease,  or  those  with  most  enormous  herniie,  operation 
always  should  be  urged  upon  the  patient.  It  is  extremel}"  desirable 
to  reduce  the  size  of  these  large  hernia^  before  any  operation  is  under- 
taken, and  even  if  no  operation  is  done  the  patient  may  secure  much 
relief  from  the  preliminary  treatment.  This  plan  is  to  keep  the  patient 
in  bed,  on  spare  diet,  with  a  course  of  mild  purging,  and  frequent 
enemas,  so  as  to  secure  complete  evacuation  of  the  })owels.  Absti- 
nence and  rest  will  reduce  the  amount  of  fat  in  the  omentum  and 
mesentery;  and  recumbency,  combined  with  elevation  of  the  foot 
of  the  bed,  will  bring  the  force  of  gravity  to  aid  in  securing  reduction 
in  the  size  of  the  hernia.  This  method  appears  first  to  have  been 
advocated  by  Sir  Astley  Cooper  in  1828.  In  most  cases  a  partial  reduc- 
tion at  least  can  be  secured  by  resort  to  taxis  (p.  766)  after  a  couple  of 
weeks  of  this  preparatory  treatment,  and  sometimes  the  entire  hernia 
can  be  reduced.  In  these  cases  of  immense  hernia,  if  the  surgeon 
thoughtlessly  undertakes  an  operation  without  such  preparatory 
treatment,  he  may  find  it  impossible  to  make  the  viscera  enter  the 
abdomen  even  after  this  has  been  opened.  If  the  hernia  can  be 
reduced  to  ordinary  size  before  operation  is  attempted,  this  should 
be  as  successful  in  obtaining  a  cure  as  in  cases  of  reducible  hernia. 

If  the  patient  refuses  operative  treatment,  the  application  of  some 
form  of  support,  in  the  nature  of  a  "bag-truss"  or  suspensory  may 
somewhat  alleviate  the  symptoms. 

Inflamed  and  Obstructed  Hernia. — These  conditions  are  met  with 
almost  solely  in  cases  of  irreducible  hernia.  Inflammation  may  occur 
from  accidental  trauma,  from  unskilled  or  violent  attempts  at  reduc- 
tion, from  the  pressure  of  an  ill-fitting  truss,  or  from  changes  in  the 
contents  of  the  sac.  Among  the  latter  attention  may  be  called  to 
the  occasional  presence  of  the  vermiform  appendix  in  the  sac,  with  the 
possibility  of  appendicitis.  Ohsirudion  of  a  hernia  is  said  to  occur 
when  the  normal  course  of  gas  or  feces  through  the  herniated  bowel  is 
interrupted ;  this  may  result  from  intestinal  indigestion  with  accumu- 
lation of  flatus,  or  from  fecal  impaction  (p.  889).  The  symptoms  of 
inflamed  and  obstructed  hernia  are  much  the  same,  consisting  in 
local  pain,  tenderness,  nausea,  and  perhaps  vomiting;  the  hernia  still 
gives  an  impulse  on  coughing;  and  flatus  is  passed  by  the  anus,  though 
there  may  be  constipation.  The  symptoms  are  decidedly  less  severe 
than  in  the  case  of  strangulation. 

Treatment. — The  patient  should  be  put  to  bed,  and  should  lie  in  a 
position  which  relaxes  the  hernial  orifice;  an  ice  bag  should  be  applied 
locally;  an  enema  should  be  administered;  nothing  ichatever  should 
be  given  by  mouth;  and  if  the  symptoms  are  severe  or  if  they  do  not 
subside  in  the  course  of  a  few  hours,  operation,  as  in  cases  of  stran.- 
gulation,  becomes  imperative.  In  any  case  where  the  condition  of 
strangulation  cannot  be  positively  excluded,  immediate  operation 
should  be  done. 


STRANGULATED  HERNIA  TCI 

Incarcerated  Hernia. — This  is  one  wliicli,  th()ii<^li  ordinarily  re- 
(lii(il)le,  lias  tor  some  reason  become  temporarily  irredncihle  (l)e 
(iarmo).  This  eomplieation  occurs  most  often  in  larj^e  herniie,  and 
usually  is  due  to  unskilful  attempts  at  reduction,  resulting?  in  some 
slight  twist  in  the  howel  which  renders  the  hernial  orifice  relatively 
too  small  to  allow  reduction.  Wiiile  there  may  l)e  some  local  pain 
and  tenderness,  there  are  no  symptoms  of  stranj^ulation  present. 

Treatment. — Treatment  consists  in  rest  in  bed,  with  the  foot  of  the 
bed  elevated  and  the  ])atient  so  ])laced  as  to  relax  the  hernial  orifice. 
An  ice  bag  or  cold  coil  should  be  applied  to  the  hernia,  and  the  surgeon 
should  not  attempt  to  reduce  the  hernia  until  the  acute  symptoms 
have  had  a  chance  to  subside;  he  maj^  find  then  that  the  hernia  has 
been  spontaneously  reduced,  or  that  its  reduction  })y  taxis  (p.  760)  is 
easy.  If  the  symptoms  do  not  subside  within  a  few  hours,  taxis  should 
be  tried,  and  if  this  fails,  operation  should  be  done  as  in  cases  of 
strangulated  hernia. 

Strangulated  Hernia. — This  is  one  in  which  the  circulation  of  blood 
is  obstructed  or  entirely  arrested.  This  serious  occurrence  is  lial)le 
to  bring  on  all  the  usual  consequences  of  strangulation,  which  are 
studied  at  p.  762. 

The  cause  of  strangulation  of  a  hernia  is  not  always  evident.  It 
is  clear  that  a  constriction  exists,  pressing  upon  the  protruded  struc- 
tures and  interfering  with  their  circulation.  This  constriction  may  be 
either  in  the  sac  wall,  in  the  surrounding  structures,  or  inside  of  the 
sac.  Constriction  by  the  sac  itself  is  rare,  especially'  in  children;  the 
site  of  constriction  usually  is  at  the  neck  of  the  sac,  particularly  in 
the  case  of  patients  who  have  long  worn  a  truss  and  in  whom  the  sac 
and  its  neck  have  undergone  cicatricial  contraction.  In  some  cases  of 
congenital  sacs  points  of  constriction  may  exist  elsewhere  than  at  the 
neck  (Fig.  780) ;  and  in  some  cases  constriction  may  occur  from  bands 
of  inflammatory  adhesions  formed  within  the  sac.  Extra-saccular 
constriction  is  by  far  the  most  frequent  form  and  usually  occurs  at  the 
abdominal  opening  in  fascial  or  tendinous  tissue  through  which  the 
sac  and  its  contained  viscera  pass.  Intra-saccular  constriction,  which 
is  rarest  of  all,  may  be  due  to  torsion  of  the  contents  of  the  sac,  or  to 
the  bowel  being  caught  in  an  aperture  or  pocket  in  the  omentum. 

Mechanism  of  Strangulation. — As  the  neck  of  the  sac  and  the  abdomi- 
nal opening  through  which  the  hernia  passes  are  not  muscular,  but 
fibrous,  and  hence  have  no  power  of  active  contraction,  it  is  evident 
that  in  cases  of  extra-saccular  as  in  those  of  intra-saccular  constriction 
the  prime  cause  of  strangulation  lies  in  the  contents  of  the  sac.  If 
the  hernia  previously  was  reducible,  these  changes  in  the  contents 
of  the  sac  usually  b^gin  as  the  state  already  described  as  incarcera- 
tion of  the  hernia;  in  the  case  of  irreducible  hernia  the  first  changes 
usually  are  those  described  as  inflammation  or  obstruction  of  the  hernia, 
and  they  may  be  brought  on  by  the  unwelcome  intrusion  into  the 
sac  of  a  coil  of  gut  or  a  plug  of  omentum  never  before  present.  In 
some  patients  a  hernia  which  is  suddenly  developed  becomes  stran- 


762  HERNIA 

filiated  iinmodiately  on  its  first  appearance;  sucli  a  strangulation  is 
apt  to  cause  rapid  and  very  serious  changes  in  the  contents  of  the  sac. 
A  siniihir  chain  of  events  usually  occurs  when  a  hernia  suddenly  pro- 
trudes into  a  sac  which  has  long  been  empty,  especially  if  the  use  of 
a  truss  has  caused  cicatricial  contraction  in  the  neck  of  the  sac.  This 
form  of  strangulation  may  he  described  as  ixnde  to  distinguish  it  from 
that  of  more  chronic  onset,  which  usually  is  i)receded  by  incarceration, 
inflammation,  or  obstruction  of  the  hernia. 

All  irreducible  hernife  are  more  liable  to  strangulation  than  those 
which  are  reducible  and  are  retained  by  a  truss.  An  irreducible 
umbilical  hernia  is  especially  liable  to  strangulation;  and,  of  all  forms, 
a  femoral  heniia  is  most  prone  to  strangulation.  Neutral  and  inci- 
sional hernise  very  rarely  become  strangulated. 

Structural  Changes  Occurring  in  Strangulation. — Probably  in  every 
case  the  first  change  is  obstruction  of  the  venous  circulation  of  the 
contents  of  the  sac;  the  arterial  circulation  is  less  rapidly  affected 
because  of  the  higher  blood-pressure  in  the  arteries  and  their  more 
resistant  walls.  Arrest  of  the  venous  circulation  causes  the  blood  to 
be  dammed  back  into  the  capillaries  while  these  are  still  receiving 
blood  from  the  arterial  side.  The  result  is  stagnation  of  the  blood, 
and  edema  of  the  extravascular  tissues.  Almost  at  once  the  hernia 
becomes  too  large  to  })e  returned  through  the  orifice  by  which  it  had 
escaped.  If  intestine  is  strangulated,  intestinal  obstruction  (p.  884) 
is  present  as  well  as  strangulation,  and  usually  precedes  it. 

Strangnlatiou  of  bowel  causes  the  rapid  outpouring  of  serum  which 
may  distend  the  sac;  it  will  be  greater  in  amount  if  the  strangulation 
is  very  slow  in  onset  than  if  the  entire  circulation  is  arrested  immedi- 
ately. At  first  this  fluid  is  pale  yellow,  clear,  and  sterile,  and  perhaps 
should  be  considered  a  transudate  rather  than  an  effusion;  but  very 
soon  it  becomes  inflammatory  in  character,  turning  cloudy  from  the 
increase  in  the  number  of  leukocytes  present,  and  often  is  })loody, 
and  in  later  stages  of  strangulation,  brownish  or  black.  Bacteria  soon 
penetrate  the  walls  of  the  obstructed  bowel.  If  the  strangulation  is 
not  promptly  relie\'ed,  the  bowel,  which  at  first  is  congested,  bright 
red,  soggy,  and  with  its  natural  lustre  but  slightly  impaired,  becofnes 
purplish  or  even  black  in  color,  and  may  be  covered  with  patches  of 
inflammatory  lymph.  Actual  gangrene  quickly  follows:  the  intestine 
loses  its  lustre  entirely,  and  becomes  soft,  doughy,  and  grayish  black; 
the  peritoneal  coat  strips  easily,  the  muscular  coats  are  friable,  and 
the  bowel  is  very  easily  torn.  In  many  cases  definite  rings  of  con- 
striction are  found  at  the  points  of  strangulation:  usually  the  con- 
striction ring  at  the  distal  (anal)  end  of  the  strangulated  loop  is  more 
pronounced  than  that  at  the  proximal  (gastric)  end.  The  bowel 
below  the  constriction  is  nearly  normal  in  appearance,  or  if  anything 
rather  paler  than  normal  and  collapsed ;  that  proximal  to  the  constric- 
tion is  distended,  congested,  and  more  nearly  resembles  the  gut  which 
has  occupied  the  hernial  sac.  When  the  bowel  becomes  necrotic,  or 
even  before,  merely  as  the  result  of  intestinal  obstruction,  death  from 


STRA  NdVI.A  TKl)   II  A'/.'A 7.t 


7f)3 


toxemia  inav  occur.  If  life  is  proloii^u'd.  the  slou^rii  may  separate 
from  tlie  intestine,  resulting;  in  intestinal  perforation  mto  tlie  hernial 
sae,  which  then  hecomes  the  seat  of  a  fecal  abscess.  The  overlymf^ 
tissues  mav  next  become  inflamed,  and  in  rare  instances  this  fecal 
abscess  has  opened  spontaneously  throiiKb  the  skin.  In  many  cases 
septic  inflannnation  spreads  to  the  peritoneal  cavity,  and  f^'cneral 
periti)nitis  is  the  cause  of  death.  This  may  occur  from  perforation 
of  the  bowel  at  the  point  of  constriction  iVh^.  7()7),  with  escai)e  of 
fecal  contents  into  the  peritoneal  cavity,  or  from  propajration  of  milam- 
ination  along  the  coats  of  the  bowel  above  the  constriction.  There 
may  be  a  volvulus  of  the  intestine  leading  up  to  the  hernial  ring, 
within  the  abdominal  cavity. 


p,p  767  — Rnecimen  of  gangrenous  small  intestine  resected  in  a  case  of  strangulated 
femoral  hernia  Sesevfnty-one  years;  hernia  strangulated  for  two  weeks  before 
fperatTonFo^al  abscess  in  sac,  bowel  ruptured  just  above  proximal  constriction. 
Death  twelve  hours  after  operation  (spinal  anesthesia).    Episcopal  Hospital. 

If  omentum  is  strangulated  there  is  not  much  serum  eflfused  in  the 
sac'  The  omental  veins  are  found  distended,  dark  blue  or  black, 
and  perhaps  thrombosed.  The  omental  fat  becomes  pinkish  red  at 
first,  feels  denser  than  normal,  and  does  not  bleed  readily  if  incised; 
later  it  becomes  gravish  white  and  perhaps  necrotic. 

Symptoms  of  Strangulated  Hernia.— In  almost  every  case  the  patient 
has  had  a  hernia  for  some  time  before  it  becomes  strangulated.  Lsually 
following  a  muscular  strain  (perhaps  merely  a  mis-step,  exuberant 
laughter,  etc.)  a  sudden  pain  is  felt  at  the  site  of  the  hernia.  It  the 
hernia  was  not  down  at  the  time  of  the  accident,  it  slips  out  suddenly, 
even  escaping  from  under  a  truss  if  one  was  worn.  If  the  hernia  was 
down  alreadv  at  the  time  of  the  accident,  whether  irreducible  or  not, 
it  feels  to  the  patient  as  if  it  had  increased  in  size  from  the  protrusion 


764  HERNIA 

of  additional  bowel  or  omentum.  If  the  pain  is  very  severe  the  patient 
may  fall  to  the  ground  in  a  state  of  shock.  The  pain  is  followed  very 
soon  by  a  general  abdominal  pain  which  at  first  is  colicky,  becomes 
progressively  worse,  and  which  later  is  constant,  not  intermittent, 
//  not  checked  by  opiates  this  pain  does  not  leave  the  patient  until  gan- 
grene has  occurred  or  until  the  strangulation  is  relieved.  Spontaneous 
cessation  of  pain  therefore  is  a  bad  sign;  it  is  accompanied  by  a  false 
sense  of  security,  and  is  soon  followed  by  extreme  prostration,  and 
signs  of  impending  death  as  in  cases  of  intestinal  strangulation  from 
other  causes. 

If  the  hernia  is  an  enterocele,  the  usual  symptoms  of  intestinal 
obstruction  (p.  885)  de\elop  xevy  soon  after  the  occurrence  of  the 
strangulation.  The  initial  colicky  pain,  in  almost  all  cases  but  not 
always,  is  accompanied  or  followed  by  nausea  and  vomiting.  The 
vomiting,  which  at  first  is  the  result  of  nausea,  later  becomes  typically 
projectile  in  type,  due  not  to  nausea,  but  to  reversed  peristalsis. 
First  the  gastric  contents  are  vomited;  then  bile-stained  matter;  later 
the  contents  of  the  upper  intestine,  which  is  brownish  and  sour- 
smelling;  and  in  the  final  stages  true  fecal  or  stercoraceous  vomiting 
may  occur.  Coincident  with  these  symptoms  there  is  absolute  con- 
stipation, and  no  flatus  is  passed  by  the  rectum.  An  enema  may 
empty  the  rectum  of  what  was  already  there  or  in  the  sigmoid;  but 
after  the  lower  bowel  has  been  emptied,  no  further  movement  can  be 
obtained,  and  in  no  case  is  there  passage  of  flatus.  In  the  case  of  an 
epiplocele  the  symptoms  are  the  same  though  often  less  in  degree, 
there  being  seldom  absolute  constipation  or  complete  arrest  of  flatus. 

If  the  intestinal  obstruction  is  not  relieved,  peritonitis  will  develop, 
with  its  characteristic  symptoms  and  physical  signs  (p.  805).  Until 
this  event  occurs  the  temperature  is  not  elevated,  though  the  pulse 
slowly  but  steadily  increases  in  rapidity. 

Physical  examination  shows  a  tender,  painful,  and  tense  swelling 
at  the  site  of  the  hernia.  In  the  case  of  a  large  hernia  long  irreducible, 
these  signs  are  not  so  apparent,  but  usually  it  is  evident  that  the 
swelling  is  somewhat  more  tense  and  painful  than  before  the  onset  of 
the  symptoms  of  strangulation.  In  an  omental  hernia  the  swelling  is 
boggy,  rather  than  tense.  There  is  no  impulse  in  a  strangulated  hernia 
when  the  patient  coughs.  Palpation  of  the  abdomen  usually  reveals 
rigidity  of  the  abdominal  muscles  near  the  site  of  the  hernia;  it  is  a 
voluntary  rigidity,  not  like  that  which  results  from  peritonitis.  Auscul- 
tation of  the  abdomen  detects  sounds  of  borborygmi  characteristic 
of  peristalsis;  usually  these  peristaltic  noises  are  exaggerated,  and 
sometimes  they  may  be  traced  up  to  the  site  of  obstruction,  where 
they  are  arrested  with  a  distinct  click. 

Diagnosis  of  Strangulated  Hernia. — This  depends  on  recognizing,  in 
addition  to  the  symptoms  of  intestinal  obstruction,  the  existence  of 
a  hernia  with  the  signs  characteristic  of  strangulation.  If  the  latter 
condition  is  present,  it  is  not  necessary  to  wait  for  full  development 
of  symptoms  of  intestinal  obstruction  before  making  a  diagnosis.     I 


STRANGULATED  HERNIA  7G5 

lia\c  st'\or;il  times  found  a  guii^rciious  patch  on  tlie  b(nvel  in  cases 
wliore  neither  nausea  nor  vomiting  had  been  present,  althougli  the 
strangulation  had  histed  for  from  six  to  eiglit  hours.  In  very  fat 
patients  it  may  he  impossihk'  to  detect  with  certainty  a  very  small 
hernia.  All  the  usual  sites  of  liernia  should  he  carefully  examined, 
and  corresponding  parts  of  the  body  should  l)e  comj)ared  most  dili- 
gently in  obscure  cases.  A  feeling  of  greater  resistance  over  one  hernial 
ring  than  at  the  corrcsj)()nding  point  on  the  other  side  of  the  body  may 
be  the  only  pliysical  sign  discernible  in  a  case  of  partial  enterocele 
(Richter's  hernia);  but  such  small  herniae  may  become  gangrenous 
much  sooner  than  larger  hernia\  If  two  hcrriicp,  both  irreducible,  are 
present,  it  may  be  difficult  to  decide  which  of  the  two  is  strangulated; 
usually  the  physical  signs  (absence  of  impulse  on  coughing,  greater 
tension  and  tenderness  in  the  neck  of  the  strangulated  hernia)  will  be 
of  more  aid  in  such  cases  than  the  history  and  subjective  symptoms. 
An  irreducible  hernia  may  be  present  and  there  may  be  ijeritonitis 
from  some  other  cause.  The  distinctions  between  intestinal  obstruc- 
tion and  peritonitis  cannot  be  too  often  insisted  upon;  they  are  detailed 
at  p.  S09.  In  strangulated  hernia  peritonitis  is  a  late  symptom,  all 
the  early  signs  indicating  intestinal  obstruction.  There  may  be  an 
irreducible  hernia  and  yet  there  may  be  some  other  cause  for  intestinal 
obstruction:  here  again  physical  examination  will  show  an  impulse  on 
coughing  unless  the  hernia  is  strangulated;  while  a  careful  history  of 
the  case  may  throw  much  light  on  the  diagnosis  as  it  may  indicate 
previous  attacks  of  peritonitis,  leaving  crippling  bands  or  adhesions 
as  the  true  cause  of  the  symptoms.  If  no  conclusion  can  be  reached 
after  careful  study,  the  surgeon  should  expose  the  hernia  before 
proceeding  to  exploratory  laparotomy.  The  vomiting  of  pregnancy  may 
be  confusing,  if  an  irreducible  hernia  is  present;  but  the  negative 
physical  examination  of  the  hernia,  and  the  fact  that  there  is  no 
evidence  of  intestinal  obstruction,  should  be  sufficient  evidence  of  the 
true  condition.  In  some  cases  of  inguinal  hernia,  confusion  is  caused 
by  the  presence  of  an  inflamed  lymph  node  in  the  groin,  and  in  infants 
by  an  inflamed,  hydrocele  of  the  cord.  When,  as  often  in  these  cases, 
physical  examination  is  unsatisfactory,  and  the  history  is  unknown 
or  negative,  a  differentiation  may  be  impossible.  An  undescended 
testicle  need  not  be  mistaken  for  a  strangulated  hernia  if  the  surgeon 
is  cautious  enough  to  examine  the  scrotum  before  reaching  a  diagnosis. 
Treatment  of  Strangulated  Hernia. — The  object  of  treatment  is  to 
relieve  the  strangulation.  This  may  be  accomplished  (1)  by  pushing 
the  strangulated  bowel  or  omentum  back  into  the  abdominal  cavity 
by  means  of  Taxis;  or  (2)  by  operation — dividing  the  constriction, 
inspecting  the  bowel,  and  treating  it  appropriately  before  restoring 
it  to  the  abdomen.  In  most  cases  this  operation  may  be  completed 
by  repair  of  the  abdominal  wall  so  as  to  prevent  recurrence  of  the 
hernia.  The  physician  never  should  leave  his  patient  until  the  stran- 
gulation has  been  relieved,  or  until  he  has  made  arrangements  for 
immediate  surgical  treatment. 


76G  HERNIA 

Taxis. — This  is  a  term  derived  from  tlie  (ireek,  and  implying 
arrangement  or  adjustment.  It  is  used  in  surgery  in  a  technical  sense 
to  descril)e  various  manipulations  by  which  the  surgeon  seeks  to  secure 
reduction  of  a  hernia.  The  patient  should  be  placed  on  a  bed,  with 
his  shoulders  and  pelvis  raised,  so  as  to  relax  the  abdominal  muscles. 
The  surgeon  then  surrounds  the  hernial  orifice  with  the  thumb  and 
fingers  of  his  left  hand,  while  with  the  right  he  endeavors  by  very 
gentle  but  persistent  compression  to  empty  the  herniated  bowel  of 
some  of  its  gaseous  and  fluid  contents.  When  this  has  been  accom- 
jilished,  he  employs  his  right  hand  in  the  most  gentle  and  ])atient 
kneading  movements,  in  the  attempt  to  make  the  bowel  recede  into 
the  abdomen.  The  direction  of  pressure  must  correspond  to  that  by 
which  the  bowel  came  down.  Success  is  manifested  by  the  bowel 
slipping  back  into  the  abdomen  with  an  audible  gurgle  and  a  charac- 
teristic flop.  If  these  signs  are  absent,  e^'en  though  the  hernia  appears 
to  have  been  reduced,  it  is  most  probable  that  this  is  not  really  the 
case,  but  that  reduction  in  7nass  has  occurred.  This  term  implies 
that  the  contents  of  the  sac  have  been  pushed  upward  until  they  lie 
on  the  inner  aspect  of  the  abdominal  wall,  but  have  carried  before 
them  the  neck  of  the  sac,  which  is  the  seat  of  constriction;  and  that 
the  hernia,  still  strangulated,  rests  between  the  abdominal  wall  and 
parietal  peritoneum.  If  the  symptoms  of  strangulation  persist, 
operation  should  be  done  immediately. 

Contraindications  to  tJie  Taxi,^. — ^(1)  Taxis  never  should  be  employed 
if  anyone  else  already  has  attempted  it;  because  there  is  no  telling  how 
much  damage  may  have  been  done  to  the  gut,  and  in  its  present  state 
even  the  very  gentlest  manipulation  may  rupture  it  or  cause  other 
disastrous  consequences.  (2)  Taxis  never  should  be  employed  in  very 
acute  cases;  it  is  suitable  only  to  such  as  begin  with  symptoms  of 
incarceration  or  obstruction  of  the  hernia.  (3)  Taxis  never  should  be 
employed  while  the  patient  is  anesthetized,  as  there  is  too  much  risk 
of  using  unjustifiable  force.  (4)  Taxis  never  should  be  persisted  in 
for  more  than  fifteen  minutes. 

Operation. — The  operation  for  strangulated  hernia  is  one  which 
any  medical  man  may  be  called  on  to  perform  in  emergency.  It  is 
not  nearly  so  difficult  as  is  the  taxis,  and  is  incomparably  more  efficient 
in  securing  the  end  in  view — that  of  relief  of  strangulation.  If  opera- 
tion were  resorted  to  in  every  case  within  the  first  twelve  hours,  and 
with  modern  aseptic  methods,  the  mortality  of  strangulated  hernia 
would  be  only  from  3  to  5  per  cent.,  or  less  than  half  that  of  typhoid 
fever;  instead  of  as  high  as  that  of  pneumonia,  or  fracture  of  the  base 
of  the  skull,  as  it  is  now,  when  in  many  cases  the  obstinacy  of  the 
patient  or  still  worse  the  ignorance  of  the  family  physician  post- 
pones operation  until  gangrene  and  peritonitis  have  developed.  The 
mortality  when  operation  is  employed  under  such  circumstances 
varies  from  10  to  50  per  cent.,  according  to  the  constitutional  resist- 
ance of  the  i)atient.  If  no  operation  is  done,  spontaneous  cure  by 
sloughing  and  formation  of  a  fecal  fistula  may  result  in  as  many  as 
2  per  cent,  of  cases,  while  OS  per  cent,  will  terminate  in  deatii. 


STh'.WCCLATKD   IIERMA  7C)7 

TIk"  operation,  wliicli  is  known  as  licniiofoiiii/  or  ktldtoiiiy,  consists 
essentially  in  niakinij  an  incision  throuj;h  tlie  overlying  structures 
until  the  neck  of  the  sac  is  exposed;  then  the  sac  is  opened,  and  the 
constriction  causinij;  stranj^nilation  is  divided.  For  this  deep  incision 
many  surgeons  still  use  Cooper's  herniotome  (Fig.  7()S)  which  has  the 
advantages  of  a  l)lunt  ])oint  which  can  he  sli])ped  under  the  constriction 
and  a  short  cutting  edge.  The  contents  of  the  sac  are  then  replaced 
within  the  abdomen  if  they  are  in  good  condition,  and  the  wound  is 
rej)aired  as  in  an  operation  undertaken  for  the  "radical  cure"  of 
hernia.  If  the  contents  of  the  sac  are  not  in  good  condition  they  are 
treated  as  descrihed  helow    (see  Treatment  of  Complications). 


Fig.  768. — C'oopor's  horuiotoino. 

In  former  times,  before  the  days  of  aseptic  surgery,  there  was  great 
danger  of  })eritonitis  developing  after  such  an  operation,  and  much 
more  stress  was  laid  upon  the  employment  of  taxis,  and  even  in 
operating  many  surgeons  followed  the  method  of  Petit  (1760),  who 
divided  extra-saccular  constrictions  and  then  reduced  the  hernia 
icithoui  opcninc]  the  sac.  But  for  the  last  twenty  years  at  least,  the 
taxis  has  been  falling  increasingly  into  disfavor;  and  especially  since 
the  development  of  methods  of  inducing  local  anesthesia,  and  spinal 
analgesia,  have  surgeons  been  more  ready  to  resort  to  operation. 
And  I  am  convinced  that  it  should  be  clearly  understood  that  no 
patients  however  moribund  in  appearance  (unless  in  articulo  mortis) 
should  be  refused  the  hope  of  recover}'  which  operation  always  affords. 
If  the  patient  is  too  ill  to  endure  a  general  anesthetic,  and  if  no  facili- 
ties exist  for  administering  local  or  spinal  anesthesia,  there  is  no  reason 
in  the  world  why  the  operation  should  not  be  done  without  any 
anesthetic  whatever.  Our  surgical  ancestors  operated  thus  for  many 
generations,  and  in  not  an  insignificant  proportion  of  cases  recovery 
followed. 

Treat:\iext  of  Complicatioxs. — As  the  surgeon  cuts  through  the 
overlying  tissues  he  may  find  that  they  are  edematous.  This  may  be 
the  result  of  trauma  inflicted  during  attempts  at  taxis,  or  rarely  may 
be  due  to  inflammation  spreading  from  a  fecal  abscess  in  the  sac.  The 
sac  usually  is  recognized  by  its  transulucent  and  bluish  appearance. 
Usually  it  is  impossible,  and  never  is  it  requisite  for  the  surgeon  to 
recognize  the  various  layers  of  tissue  overlying  the  sac.  Each  of  the 
deeper  layers  as  it  appears  should  be  cut  through  cautiously,  as  one 
opens  the  peritoneum,  after  raising  it  in  forceps  from  the  underlying 
structures.  In  this  way  there  is  very  little  danger  of  injury  to  the 
contents  of  the  hernial  sac.  In  most  cases  there  is  some  fluid  in  the 
sac;  if  it  is  clear  and  limpid,  it  is  not  likely  that  the  condition  of  the 
bowel  is  very  bad.  When  the  sac  is  opened  and  the  constriction 
relieved,  more  of  the  bowel  should  be  drawn  out  of  the  abdomen,  and 


768  HERNIA 

its  condition  should  be  carefully  observed.  (In  serious  cases  the  anes- 
thetic, if  given  by  inhalation,  may  be  suspended  at  this  point  in 
the  operation.)  If  the  bowel  was  merely  nipped  in  the  hernial  orifice, 
and  has  fallen  back  into  the  abdomen  as  soon  as  the  constriction  is 
relieved,  the  surgeon  never  should  neglect  to  draw  it  out  again  into 
the  wound  to  ascertain  its  condition.  The  next  step  is  the  application 
to  the  bowel  of  hot  (115°  F.)  sterile  hot  water  or  saline  solution. 
The  hot  fluid  should  not  be  poured  over  the  bowel  with  any  force, 
but  should  be  allowed  to  flow  gently  over  the  bowel  so  as  to  avoid  the 
trauma  even  of  a  current  of  water.  Nor  should  the  bowel  be  sub- 
jected to  massage  or  to  irritation  by  gauze  sponges.  The  bowel  should 
be  examined  for  its  lustre,  its  color,  and  its  elasticity.  Though  the 
color  when  first  exposed  may  be  bright  red,  bluish,  dark  blue,  purple, 
or  even  black,  it  may  return  to  normal  after  relief  of  the  strangulation 
and  application  of  hot  solutions  for  a  varying  time  up  to  half  an  hour. 
If  the  gut  is  entirely  gangrenous  when  first  seen,  of  course  it  is  hope- 
less to  expect  its  recuperation;  but  recovery  may  occur  from  any 
stage  short  of  gangrene;  and  a  patch  of  seeming  gangrene  which  at 
first  appears  so  large  as  to  demand  resection,  may  be  so  much  dimin- 
ished in  size  by  hot  applications  as  to  permit  of  retention  of  the  bowel 
after  inversion  of  the  worst  portions.  If  the  lustre  of  the  peritoneal 
coat  is  preserved,  as  a  rule  the  color  will  return  to  the  normal  and  the 
bowel  will  survive.  If  the  mesenteric  vessels  cannot  be  felt  pulsating 
the  bowel  will  not  survive.  If  the  bowel  fills  out  with  its  contained 
air  and  retains  its  normal  cylindrical  form,  it  is  more  apt  to  be  healthy 
than  if  it  has  lost  its  resiliency  and  retains  any  indentation  or  crease 
accidentally  produced  during  manipulation.  Careful  inspection 
should  be  made  also  of  the  circular  constrictions  on  the  bowel  at  the 
points  of  strangulation,  if  such  constrictions  exist.  There  may  be  a 
threatening  perforation  here,  while  the  intervening  portion  of  bowel 
which  was  not  directly  compressed,  but  had  its  circulation  impaired 
only  by  pressure  on  its  mesentery,  may  be  fairly  normal. 

If  the  bowel  returns  to  its  normal  condition,  it  should  be  replaced, 
and  the  wound  should  be  closed.  If  a  suspected  spot  remains,  it  often 
is  possible  to  cover  it  in  by  inverting  it  and  suturing  neighboring 
healthy  portions  of  bowel  over  it,  as  indicated  in  the  accompanying 
diagrams.  Even  though  the  entire  lumen  of  the  gut  appears  to  be 
obstructed  by  the  amount  of  its  wall  inverted,  recovery  without  any 
untoward  symptom  may  occur  (Fig.  7(39).  The  sero-sero;us  suture 
is  used,  as  in  other  intestinal  operations  (p.  830).  If  the  circular 
constriction  at  the  point  of  strangulation  has  been  very  tight,  it  will 
have  crushed  all  the  coats  of  the  bowel  except  the  peritoneum  at  this 
point,  just  as  if  a  compression  forceps  had  been  applied  to  the  gut 
previous  to  the  application  of  a  ligature.  In  such  circumstances  the 
ring  of  constriction  sometimes  may  be  covered  in  by  producing  a 
partial  intussusception  of  the  bowel  (Fig.  770). 

Onl}^  if  there  is  actual  gangrene  is  resection  desirable;  and  even  in 
such  cases,  if  the  patient's  condition  is  very  bad,  or  if  the  operator  is 


STRANGULATED  HERNIA 


709 


inexperienced,  it  will  1)0  c[uite  sufficient  to  leave  the  gangrenous  coil 
of  intestine  lying  in  the  sac,  after  relieving  the  constriction,  and 
packing  sterile  gau/e  around  the  bowel,  which  should  then  be  opened 
and  drained.  If  the  proximal  (afferent)  bowel  is  very  much  distended, 
or  if  the  strangulation  has  existed  a  long  time,  it  always  is  well  to 
evacuate  ihe  rouietds  of  the  proximal  loop  (wliich  in  such  cases  are 
regarded  as  highly  toxic),  instead  of  allowing  these  contents  to  pass 
on  down  through  the  intestinal  canal,  whence  absorption  may  occur, 
causing  increased  toxemia. 


Fig.  70!). — Gangrenous  spot  on  bowel 
(a),  inverted  into  lumen  by  sutures  (b). 
From  a  patient  in  the  Episcopal  Hospital. 
Recovery. 


Fig.  770. — Gangrenous  area  involving 
nearly  whole  circumference  of  bowel  (a), 
successfully  treated  by  producing  a  partial 
intussusception  (b).     Episcopal  Hospital. 


^Miere  resection  of  the  bowel  is  done  the  surgeon  may  terminate 
the  operation  either  by  establishing  a  false  anus  in  the  wound,  or 
by  completing  an  intestinal  anastomosis.  The  former  should  be 
selected  in  all  cases  where  a  prolongation  of  the  operation  is  not 
desirable,  unless  the  site  of  resection  is  very  high  in  the  intestinal 
canal.  When  an  anastomosis  is  done  it  may  be  either  an  end-to-end 
anastomosis  or  a  lateral  anastomosis  (p.  833).  In  these  cases  no  fur- 
ther prolongation  of  the  operation  is  desirable,  so  no  attempt  at  a 
"radical  cure"  of  the  hernia  should  be  made;  it  is  sufficient  to  close 
the  wound,  usually  with  drainage,  in  the  simplest  and  most  expe- 
ditious manner. 

The  treatment  of  omentum  found  in  the  sac  demands  a  few  words  of 
explanation.  If  there  is  no  serious  change  in  this  structure,  it  may  be 
replaced;  but  if  there  is  any  doubt  about  its  condition,  it  should  be 
49 


770 


HERNIA 


excised,  after  tyiiifj  it  oti'  where  normal  by  a  series  of  interlocking 
ligatures,  below  which  it  is  cut  away,  leaving  a  sufficient  stump  to 
ensure  that  the  ligatures  will  not  slip.  Each  ligature  should  include 
no  more  than  a  pencil's  thickness  of  the  omentum,  and  the  omentum 
should  be  excised  before  the  ligatures  are  cut  short,  so  that  the  sur- 
geon may  use  them  to  hold  the  omental  stump  in  the  wound  for  careful 
inspection,  to  make  sure  that  hemorrhage  is  controlled.  The  omental 
bloodvessels  have  no  muscular  coats,  and  do  not  retract  or  contract 
and  allow  spontaneous  cessation  of  bleeding.  Not  unfrequently  the 
omentum  protrudes  in  a  loop,  into  the  hernial  sac  (Fig.  771),  and  unless 


Fig.  771. — Loop  of  omentum  protruding  into  hernial  sac,  but  having  its  free  end 
within  the  abdominal  cavity.  Complications  might  ensue  if  this  free  end  was  not 
drawn  out  before  Hgating  and  cutting  off  the  omentum. 

care  is  taken  to  pull  the  end  of  the  loop  out  of  the  abdomen  before  its 
base  is  ligated  there  will  be  danger  of  its  necrosing  and  causing  peri- 
tonitis or  obstruction  later.  The  omentum  is  so  seldom  normal  when 
it  has  been  long  in  a  hernial  sac,  even  if  not  strangulated,  that  I  believe 
it  is  much  better  to  excise  it  under  all  circumstances,  unless  the  con- 
dition of  the  patient  is  such  as  to  render  any  prolongation  of  the 
operation  unjustifiable.  If  it  is  restored  to  the  abdomen  it  is  quite 
likely  to  cause  subsequent  trouble  either  by  adhesions  or  by  favoring 
recurrence  of  the  hernia  (Lucas-Championniere). 

The  after-treatment  is  the  same  as  after  other  operations  for  intestinal 
obstruction.  If  the  wound  has  not  been  securely  repaired,  the  patient 
should  be  operated  on  after  complete  recovery,  to  obtain  a  radical 
cure;  or  a  truss  should  be  worn  to  prevent  reappearance  of  the  hernia. 


SPECIAL  HERNI-ffi.    ' 

Classification. — There  are  only  three  forms  of  hernia  of  frequent 
occurrence;  all  the  others  are  rare.  The  most  frequent  form  is  the 
inguinal,  which  occurs  in  about  73  per  cent,  of  cases;  then  comes  the 
femoral,  in  about  18  per  cent,  of  cases;  and  lastly  the  nmbilical,  which 
occurs  in  about  8.5  per  cent,  of  cases.     This  leaves  about  1  per  cent. 


EPIGASTRIC  HERNIA  771 

f.,r  tl„.  n,r,T  forms  (luinl.ar,  „l,turat„r.  ,-t,-.).  1"  /Lis  reckoninK 
Wv  T  ,K-isi,„ul  iKTMi.  is  not  inclu.lo,!.  T„  aHor,l  a  persp«-tus„l 
tl,rsul.i;.ct  to  tlu.  student,  tlKTC  is  n,.  nu,ro  s.-rvnoablc  class,h,at,on 
of  licrniii  than  the  follov/ing: 

ITeRNLE   of  the   El'KiASTKIC   REGION. 

1.  Diaphriiuinatio. 

2.  F.pi gastric. 

IIeunle  of  the  Mesogastric  Region. 

1.  WMitral 

2.  Incisional— These  mjiy  occur  also  m  other  regions. 

0.  I'mbilical. 
4.  Lumbar. 

Hernle  of  the  Hypogastric  Region. 

1.  Inguinal. 

1.  Indirect  (or  Oblique). 

2.  Direct. 

2.  Femoral  or  Crural. 

3.  Pelvic. 

1.  Anterior— obturator. 

r  (1)  Perineal. 

2.  Inferior   <  (2)  Pudendal. 

t  (3)  Vaginal. 
.     /  (1)  Ischiatic. 

3.  Posterior!  (2)  Gluteal. 

These  various  forms  will  now  be  discussed  in  turn.  Diaphragmatic 
Herniah..  already  been  considered  (p.  751).  Internal  Hernm  is 
discussed  in  Chapter  XXII.  ,, 

Epigastric  Hemia.-By  this  term  is  understood  one  or  more  sma 
protri'ions,  usually  of  omentum  only,  occurring  in  or  near  the  med  a^. 
line  of  the  abdomen  (linea  alba)  between  ensiform  process  and  um- 
bilicus. It  is  a  rare  condition,  first  well  studied  by  Terrier  m  1886. 
A  much  more  frequent  abnormality,  and  one  which  often  is  mistaken 
for  a  ture  hernials  the  protrusion  of  small  portions  of  the  vrep^n- 
toneal  fat  through  apertures  between  the  ^rf^^verse  fibres  of  the 
sheaths  of  the  recti  muscles  which  go  to  form  the  linea  alba  Accord- 
ing to  Tillaux  (1894)  it  is  more  frequent  in  men.  The  patient  com- 
pkins  of  pain,  and  on  examination  a  small  mass  can  be  felt  the  size  of 
a  ilarble  or  thereabouts,  and  generally  irreducible.     It  simulates  an 

'^TrtTment.-If  the  application  of  firm  pressure  by  adhesive  plaster 
or  an  abdominal  belt  does  not  afford  relief  tl.e  ^fy'TLZhX 
excised,  after  exposing  and  ligating  its  pedicle.  If  the  Imea  alba  is 
carefully  sutured  there  is  not  apt  to  be  a  recurrence. 


772 


HERNIA 


Ventral  Hernia. — This  hernia  may  occur  in  any  part  of  the  abclomi- 
nal  wall,  but  does  not  protrude  through  one  of  the  usual  apertures 
such  as  the  umbilicus,  the  inguinal  or  femoral  canals,  etc.  It  is  a 
very  rare  form  of  hernia,  though  by  many  surgeons  it  is  not  distin- 
guished from  incisional  hernia  (see  below).  The  usual  cause  is  injury 
resulting  in  partial  rupture  of  the  alxlominal  muscles,  from  a  direct 
blow  or  merely  by  muscular  strain.  In  some  cases  no  distinct  history 
of  injury  can  be  obtained,  the  abdominal  wall  seeming  to  have  yielded 
spontaneously  at  the  site  where  the  hernia  appears  (Fig.  772).  No 
true  sac  exists,  the  parietal  peritoneum  merely  bulging  a  little  when 
the  patient  strains. 


Fig.  772. — Ventral  hernia  through  right  olJiciue  muscles. 
Episcopal  Hospital. 


(Dr.  Neilson's  case.) 


Under  the  heading  of  ventral  hernia  may  be  included  also  protru- 
sion due  to  diastasis  of  the  recti  muscles  in  the  mid-line.  A  slight 
degree  of  diastasis  is  normal  above  the  umbilicus,  but  pathological 
diastasis  usually  is  seen  in  the  hypogastric  region,  and  occurs  in 
women  who  have  borne  many  children  and  who  are  emaciated.  A 
similar  condition  is  frequently  seen  in  infants  and  young  children,  as 
a  congenital  deformity. 

Symptoms. — The  s^^mptoms  of  ventral  hernia  are  a  feeling  of  weak- 
ness at  the  site  of  the  protrusion,  and  dragging  sensations  within  the 
abdomen.  The  diagnosis  is  not  difficult,  if  the  possible  existence  of 
the  condition  is  remembered. 

Treatment. — Usually  symptomatic  relief  is  secured  by  wearing  a 
firm  abdominal  belt.  In  children  with  diastasis  of  the  recti  the  use 
of  adhesive  plaster  strapping  as  advised  in  cases  of  umbilical  hernia 
usually  effects  a  cure.  Even  in  adults  the  hernia  is  not  liable  to  com- 
plications, but  if  desired  the  patient  can  secure  permanent  relief  by 
an  operation  as  for  incisional  hernia. 

Incisional  Hernia. — This  is  much  more  frequent  than  a  true  ventral 
hernia,  and  receives  its  name  from  its  development  in  the  cicatrix  of 
an  operative  incision.     One  cannot  too  much  insist  upon  the  impor- 


INCISinyAL  HERNIA 


11?> 


tauoc  ol"  placiiiii  the  incision  so  as  to  do  as  little  (iainage  as  possiljle  to 
the  structures  of  the  al)(h)niinal  wail  (see  p.  818).  Incisional  hernia 
was  nnich  more  t"rc([U(Mit  I'ornierly  when  less  care  was  taken  in  the 
repair  ot"  alxloniinal  wounds.  An  incisional  hernia  is  very  rare  in  a 
clean  wound  which  is  closed  completely  by  tier  suture.  If  the  wound 
is  drained,  a  hernia  is  much  more  apt  to  develop. 


Fig.  773. — Incisioiuil  hernia,  in  scar 
of  operation  for  appendicitis  .seven 
years  ago  (incision  in  right  semilunar 
line).     Episcopal  Hospital. 


Fig.  774. — Incisional  hernia,  in  scar  of 
operation  for  typhoid  perforation  of  intes- 
tine nine  years  ago  (right  rectus  incision). 
Two  years  ago  a  right  inguinal  hernia  also 
developed.  Age  thirty-six  years.  (Dr. 
Harte's  case.)     Episcopal  Hospital. 


This  form  of  hernia  may  be  of  any  size,  and  if  large  may  cause 
very  great  disability.  Usually  there  is  no  true  peritoneal  sac,  but  the 
abdominal  viscera  lie  in  direct  contact  with  fascia  or  skin,  and  almost 
always  are  closely  adherent  to  their  coverings.     Owing  to  this  fact 


Fig.  775. — Incisional  heinia  one  year  after  operatii^n  for  api^endicitis  (right 
rectus  incision).     Children's  Hospital. 

there  is  no  chance  for  spontaneous  cure  even  if  the  hernia  is  kept 
reduced  by  suitable  appliances.  As  the  abdominal  opening  is  rela- 
tively large,  strangulation  or  other  lesser  complication  is  rare;  though 
incarceration  may  occur  if  the  aperture  is  small. 

The  symptoms  are  the  same  as  in  ventral  hernia. 


774  HERNIA 

Treatment.  -If  the  patient  is  healthy,  operation  should  he  clone. 
If  this  is  contraindicated,  an  abdominal  belt,  as  in  cases  of  pendulous 
abdomen  (Fig.  875),  may  relieve  the  worst  symptoms.  When  operation 
is  done  it  should  be  remembered  that  the  cicatrix  is  usually  very  thin 
and  the  hernial  contents  adherent.  The  surgeon,  therefore,  begins  by 
an  incision  at  the  periphery  of  the  hernia,  and  opens  the  abdomen  not 
directly  through  the  old  cicatrix,  but  through  healthy  tissues  above 
or  below  or  to  one  side  of  the  hernia.  Here  there  will  be  no  adhe- 
sions to  the  parietal  peritoneum.  The  hernial  contents  are  then 
cautiously  dissected  free  from  the  overlying  abdominal  wall,  the  cica- 
tricial tissue  is  excised,  and  the  herniated  structures  reduced.  In 
cases  of  very  large  hernia  with  many  adhesions  between  the  prolapsed 
intestines  and  omentum  it  is  not  desirable  to  separate  these  more 
than  is  required  to  free  the  different  layers  of  the  abdominal  wall. 
Redundant  or  diseased  omentum  should  be  excised.  The  various 
layers  of  the  abdominal  wall,  especially  the  aponeuroses,  should  be 
dissected  free,  exposing  enough  of  each  for  accurate  suture,  and  if 
possible  for  overlapping.  Then  the  wound  should  be  repaired  as  a 
recent  abdominal  incision  (p.  821).  The  most  important  layer  of  the 
abdominal  wall  to  suture  accurately  is  the  anterior  sheath  of  the  rectus 
or  the  aponeurosis  of  the  external  oblique.  Hemostasis  should  be 
absolute,  and  the  wound  should  not  be  drained.  The  patient  should 
remain  in  bed  for  at  least  three  weeks,  and  if  the  hernia  was  large 
should  wear  an  abdominal  belt  and  avoid  straining  efforts  for  a  year 
after  operation.  Bartlett  (1903)  and  other  surgeons  have  implanted 
silver  wire  filigree  in  these  wounds,  with  a  view  of  rendering  them 
stronger.  Recent  experience  has  shown  that  free  flaps  of  fascia  lata 
can  be  transplanted  to  supply  the  defect. 

Umbilical  Hernia. — This  is  a  frequent  affection,  especially  in 
infants  and  stout  adults  past  middle  life.  Three  forms  are  to  be 
distinguished,  the  Congenital,  the  Infantile,  and  the  Adult. 

Congenital  Umbilical  Hernia  is  rare,  occurring  once  in  five  or  six 
thousand  births.  It  is  classed  as  embryonic  and  fetal.  The  former  is 
due  to  failure  of  development  of  the  abdominal  wall,  and  the  hernia, 
or  rather  eventration,  may  be  very  extensive,  containing  beside 
intestine  also  stomach,  liver,  heart,  etc.  The  fetal  variety  develops 
after  the  third  month  of  intra-uterine  life,  and  the  sac  is  lined  by 
peritoneum  and  seldom  is  very  large.  Infants  with  large  embryonic 
hernia  usually  are  stillborn,  or  die  so  soon  after  birth  as  to  offer  little 
chance  for  repair  of  the  defect  by  surgical  means.  The  smaller  fetal 
hernia  usually  is  covered  only  by  a  translucent  membrane  through 
which  the  herniated  viscera  can  be  seen.  Other  malformations,  espe- 
cially of  the  bladder  or  rectum,  may  be  present. 

Treatment. — ^The  hernia  should  be  repaired  by  operation  so  soon  as 
possible.  The  general  mortality  is  about  30  per  cent.,  but  is  less  after 
operation  done  on  the  first  day  of  life  than  later. 

Umbilical  Hernia  in  Infants  and  Children  is  very  frequent.  It  develops 
at  any  time  after  complete  cicatrization  of  the  navel,  and  seldom 


UMBILICAL   UKHNIA  i  <•) 

appears  fir.st  after  the  close  of  the  seeuiicl  year  of  life.  I'he  hernia 
seldom  is  very  large,  is  covered  by  normal  skin,  and  usually  appears 
not  directly  under  the  umbilical  cicatrix,  but  slightly  above  and  to 
one  siile.  Pressure  by  a  finger  reduces  the  hernia  easily,  and  when 
the  child  cries  or  strains  it  becomes  larger  and  more  tense  (Fig.  TTb). 
Treatment. — If  the  hernia  is  small  and  the  child  is  young,  there 
is  some  chance  of  cure  without  operation.  With  the  child  lying  down, 
one  end  of  a  strip  of  adhesive  i)laster,  about  two  inches  wide  is  fixed 
in  one  lumbar  region;  then  the  surgeon  draws  the  opposite  side  of  the 
belly  forward,  so  as  to  form  a  longitudinal  fold  in  the  region  of  the 


Fig.  776. 
rachitic    negro 
Hospital. 


Umbilical  hernia  in  a 
boy.       Children's 


Fig.  777. — Result  of  operation  for  umbilical 
hernia  with  preservation  of  the  navel.  Children's 
Hospital. 


linea  alba.  The  adhesive  plaster  is  then  drawn  across  the  relaxed 
belly  and  is  tightly  applied  to  the  loin  on  the  other  side.  It  is  well 
to  reinforce  this  first  strip  by  one  or  two  others.  It  is  better  not  to 
place  a  button,  or  a  coin,  or  pad,  or  anything  else  over  the  hernia,  as 
these  tend  to  keep  open  the  hernial  ring.  The  adhesive  plaster  should 
be  renewed  about  once  a  week,  or  as  often  as  it  comes  loose.  Care 
must  be  taken  to  keep  the  hernia  reduced  by  the  finger  while  the 
plaster  is  being  changed.  Attention  is  necessary  to  prevent  excoria- 
tions of  the  skin.  If  the  plaster  is  applied  too  tightly  it  may  encourage 
the  development  of  inguinal  hernia.     If  this  method  of  strapping  an 


776 


HERNIA 


umbilical  hernia  is  faithfully  continued  for  a  year,  a  cure  will  result 
in  a  large  number  of  cases  if  the  hernia  is  small  and  of  short  duration. 
If  no  improvement  is  apparent  within  four  or  six  months,  operation 
probably  will  be  necessary. 

Operation  for  infantile  umbilical  hernia  is  best  done  after  the  child 
is  two  years  old.  This  will  allow  a  fair  trial  of  conservative  treatment. 
I  think  it  is  well  in  children,  especially  in  boys  who  are  exposed  more 
than  girls  to  ridicule  for  any  abnormality,  to  do  an  operation  which 
permits  preservation  of  the  riavel,  as  advised  by  Stone.  I  make  a  semi- 
lunar incision,  below  the  umbilicus,  in  the  direction  of  the  folds  of  the 
skin,  and  turn  this  skin  flap  upward,  exposing  the  hernial  ring,  which 
is  treated  as  in  adults;  when  the  skin  flap  is  replaced,  the  patient's 
aspect  is  quite  normal  (Fig.  777). 


Fig.  778. — Umbilical  hernia  in  adult.     Age  fifty-two  years;  duration  two  years. 
Episcopal  Hospital. 


Umbilical  Hernia  in  Adults. — This  may  be  a  sequel  or  recurrence  of 
the  infantile  form,  or  may  dexelop  first  in  adult  life.  It  is  more  fre- 
quent in  women,  being  predisposed  to  by  repeated  pregnancies.  As 
in  infants  and  children,  the  protrusion  usually  occurs  slightly  above 
the  umbilical  cicatrix.  Omentum  is  almost  always  present  in  the 
sac,  and  generally  becomes  adherent,  rendering  the  hernia  irreducible 
at  least  in  part.  When  the  hernia  is  allowed  to  grow  large,  it  becomes 
pendulous  (Fig.  778),  and  usually  contains  transverse  colon  and  often 
small  intestine  also.  Incarceration  is  frequent,  and  strangulation  not 
unusual.  Strangulation  often  is  intra-saccular,  a  coil  of  gut  being 
caught  in  the  matted  and  hypertrophied  omentum.  The  coverings 
of  the  hernia  are  skin,  subcutaneous  fat,  a  thin  layer  of  fascia,  pre- 
peritoneal fat,  and  peritoneum;  the  latter  forms  the  sac,  which  is 
acquired,  not  congenital.  The  pressure  of  the  hernia  causes  atrophy 
of  the  tissues  overlying  it,  and  the  contents  of  the  sac  usually  lie  very 
close  to  the  skin,  at  least  over  the  fundus  of  the  sac.  In  most  cases 
there  is  also  considerable  diastasis  of  the  recti  muscles,  both  above 
and  below  the  ring. 


UMBILICAL  HERNIA  777 

Treatment. — The  best  treiitnient  is  hy  operution.  Before  tliis  is 
attempted,  however,  it  is  very  important  to  secure  reduction  of  as 
mucli  of  the  liernia  as  is  ])()ssil)le,  by  tlie  means  described  at  p.  7()(). 

A  transverse  incision  is  made,  outlining  an  ellipse  of  the  redundant 
skin,  including  the  umbilicus.  This  incision  should  extend  from  one 
semilunar  line  to  the  other,  and  in  very  fat  patients  may  have  to  be 
even  longer.  This  incision  exposes  the  anterior  sheaths  of  the  recti 
muscles  on  all  sides  of  the  hernial  ring,  and  at  some  distance  from  it. 
The  fat  is  then  dissected  off  the  aponeurosis  up  to  the  borders  of  the 
ring,  and  at  this  point  the  sac  is  cautiously  opened,  with  the  usual 
precautions  against  wounding  its  contents.  This  is  very  hard  to 
avoid,  if  an  attempt  is  made  to  open  the  sac  at  its  fundus.  The  sac 
is  then  cut  away  with  scissors  at  the  margins  of  the  hernial  ring,  on 
the  finger  as  a  guide,  and  the  parietal  peritoneum  as  cut  is  caught  in 
clamps  to  prevent  it  from  retracting  out  of  sight.  The  reducible  con- 
tents of  the  sac  are  then  replaced  in  the  abdomen.  I^sually  a  good  deal 
of  omentum  has  to  be  excised;  this  should  be  done  with  the  precau- 
tions recommended  at  p.  769.  The  skin  containing  the  umbilicus, 
circumscribed  by  the  original  incision  is  removed  in  one  piece  with  the 
hernial  sac  {Omphalectomy).  When  all  the  hernial  contents  have 
been  replaced,  a  gauze  pack  is  inserted  to  plug  the  opening  and  keep 
them  from  protruding  again.  The  next  step  is  closure  of  the  hernial 
ring:  a  transverse  incision  is  made  outward  for  about  one  inch  from  the 
hernial  ring  through  the  anterior  sheath  of  each  rectus  muscle.  Usually 
there  is  diastasis  of  these  muscles,  and  for  a  distance  of  one  inch  or 
more  on  each  side  of  the  mid-line  the  anterior  and  posterior  sheaths 
of  the  recti  may  be  in  contact.  The  anterior  sheaths  alone  are  to  be 
incised,  and  are  dissected  upward  and  downward  until  a  flap  of  this 
strong  aponeurosis  is  formed  both  above  and  below  the  hernial  open- 
ing. The  margins  of  the  neck  of  the  hernial  sac  (parietal  peritoneum), 
still  caught  in  forceps,  are  next  to  be  closed  with  sutures.  This  may 
be  accomplished  by  applying  a  purse-string  (p.  829)  if  the  ring  is  small; 
but  if  it  is  large  it  is  better  to  use  interrupted  sutures.  The  sutures 
should  include  also  the  transversalis  fascia  and  the  posterior  sheaths 
of  the  recti  muscles.  Before  the  last  suture  is  tied  the  gauze  pack  is 
removed.  The  peritoneal  cavity  being  thus  closed,  the  surgeon  catches 
in  Allis  forceps  the  free  margins  of  his  aponeurotic  flaps  already 
formed  from  the  anterior  sheaths  of  the  recti  muscles.  These  flaps 
are  then  overlapped,  the  lower  one  being  pulled  up  between  the 
upper  flap  and  the  deeper  structures,  and  they  are  sutured  together 
by  interrupted  mattress  sutures  of  chromic  catgut,  as  indicated  in 
Fig.  779.  The  free  margin  of  the  upper  flap  may  then  be  sutured  to 
the  superficial  surface  of  the  anterior  rectal  sheaths. 

Transverse  suture  of  the  wound  in  repair  of  umbilical  hernia  is 
preferable  to  longitudinal  suture  because  patients  with  umbilical 
hernia  usually  have  quite  a  pendulous  abdomen,  and  there  is  much 
more  slack  in  the  tissues  and  less  tension  on  the  sutures  if  transverse 
suture  is  adopted.    Frequently  it  is  very  difficult  if  not  impossible  to 


778 


HEHMA 


liring  together  the  edges  of  the  recti  by  a  longitudinal  suture,  because 
of  their  diastasis;  but  if  the  transverse  suture  with  overlapping  is 
employed  the  approximation  of  the  recti  is  unnecessary.  The  principle 
of  overlapping  fascial  layers  in  the  repair  of  hernia,  first  introduced 
in  1881  by  Lucas-Championniere,  was  adopted  by  W.  J.  Mayo  (1899) 
in  the  case  of  umbilical  hernia,  and  the  operation  as  above  described 
is  known  by  his  name.  He  has  since  adopted  modifications  of  the 
technique  introduced  by  Ochsner:  no  attempt  is  made  to  suture  the 
neck  of  the  sac  separately,  nor  are  transverse  incisions  made  in  the 
rectus  sheaths  for  the  purpose  of  forming  fascial  flaps.  The  opening 
in  the  abdomen  is  closed  simply  by  three  mattress  sutures  so  intro- 
duced as  to  draw  its  lower  margin  well  up  beneath  its  upper.    I  have 


Fig.  779. — Radical  repair  of  umbilical  hernia.  The  parietal  peritoneum  has  been 
sutured,  and  the  lower  aponeurotic  flap  (anterior  sheaths  of  the  recti  muscles)  is  being 
drawn  up  underneath  the  upper  flap  by  means  of  mattress  sutures. 


always  used  the  original  method,  and  believe  it  is  preferable  except 
where  the  hernial  orifice  is  quite  small.  The  patient  should  be  confined 
to  bed  at  least  for  three  weeks;  and  if  the  hernia  was  very  large  or  the 
abdomen  very  pendulous,  an  abdominal  belt  should  be  v.'orn  for  several 
months.    Recurrence  is  very  unusual. 

Strangulated  Umbilical  Hernia. — This  is  a  very  serious  condition; 
the  patient  frequently  is  old,  feeble,  asthmatic,  fat,  and  arterio- 
sclerotic. The  hernia  in  most  cases  is  already  irreducible;  strangula- 
tion usually  begins  with  symptoms  of  incarceration,  and  the  develop- 
ment of  complete  strangulation  is  difficult  to  recognize,  owing  to  the 
frequency  of  intra-saccular  strangulation.  Taxis  should  not  be  per- 
sisted in  unless  the  patient  absolutely  refuses  operation.  Operation 
usually  is  too  long  delayed.    When  done,  no  attempt  should  be  made 


INGUINAL  HERNIA  770 

to  coinplt'tf  tin-  procrdiirc  l)y  ri'pair  (if  tlif  licriiial  orifice  if  tlit-  licriiia 
has  been  lon^  irreducible,  or  if  the  patient's  condition  is  bad.  It  is 
sufficient  to  relieve  tlie  strangulation,  and  the  herniated  structures 
may  be  left  adherent  to  the  sac,  and  should  not  be  reduced. 

Lumbar  Hernia. — This  is  (piite  rare.  The  protrusion  occurs  through 
I'etits  triangle,^  which  is  bounded  below  by  the  crest  of  the  ilium, 
in  front  by  the  external  oblique  and  behind  by  the  latissimuss  dorsi 
nniscle.  The  fioor  of  this  triangular  space  is  formed  l)y  the  internal 
oi)li(lue  muscle  or  its  posterior  ai)oneurosis,  whicli  is  continuous  and 
identical  with  the  lumbar  aponeurosis,  with  which  the  transversalis 
muscle  and  transversalis  fascia  are  here  fused  (Fig.  916).  The  cover- 
ings of  the  hernia  are  skin,  sui)erficial  fascia,  lumbar  aponeurosis 
(or  internal  ol)lique),  ])reperitoneal  fat,  and  ])eritoneum. 

Most  of  the  cases  of  lumbar  hernia  on  record  have  been  either  con- 
genital (probably  due  to  abnormal  size  of  Petit's  triangle),  or  the  result 
of  trauma.  The  condition  presents  the  usual  symptoms  and  physical 
signs  of  a  reducible  hernia  (p.  756),  and  must  be  distinguished  from 
a  cold  abscess,  as  well  as  from  a  lipoma.  There  is  no  distinct  neck  to 
the  sac.     Strangulation  is  unusual. 

Treatment. — If  the  patient  wears  a  well-fitting  truss  for  a  \ear  or 
more,  there  is  fair  probability  that  a  small  hernia  may  cease  to  pro- 
trude. In  most  cases,  however,  operative  treatment  is  preferable. 
This  consists  in  dissecting  out  the  layers  of  the  abdominal  wall,  and 
overlapping  them  by  sutm"e  whenever  this  is  possible.  Dowd  (1907) 
turned  up  a  flap  from  the  fascia  lata  covering  the  gluteal  region, 
to  aid  in  closure  of  the  opening. 

Inguinal  Hernia. — Of  the  three  usual  forms  of  hernia,  inguinal, 
femoral,  and  umbilical,  inguinal  hernia  is  by  far  the  most  frequent. 
It  comprises  a.bout  three-fourths  of  all  cases  of  hernia,  and  is  much 
more  frequent  in  men  than  in  women.  In  males,  9()  per  cent,  of 
hernias  are  inguinal,  about  2.5  per  cent,  are  femoral,  and  only  1  per 
cent,  are  umbilical.  In  females,  50  per  cent,  are  inguinal,  33  per  cent, 
are  femoral,  and  16  per  cent,  are  umbilical  (De  Garmo). 

Nomenclature. — If  the  hernia  emerges  from  the  peritoneal  cavity 
at  the  internal  abdominal  ring,  traverses  the  inguinal  canal,  and  ap- 
pears at  the  external  abdominal  ring,  it  is  called  an  indireci  or  oblique 
inguinal  hernia.  If  it  passes  directly  through  the  abdominal  wall  on 
the  median  side  of  the  deep  epigastric  artery,  and  thus  appears  at  the 
external  ring  without  traversing  the  inguinal  canal,  it  is  called  a  direct 
inguinal  hernia.  This  is  much  rarer  than  the  indirect  form.  If  the 
hernia  remains  above  the  brim  of  the  pelvis,  it  is  called  an  incomplete 
inguinal  hernia,  or  a  bubonocele;  if  it  descends  beyond  the  brim  of  the 
pelvis  it  is  called  a  complete  inguinal  hernia.  A  complete  inguinal 
hernia  in  the  male  enters  the  scrotum  and  is  termed  a  scrotal  hernia; 
in  the  female  it  enters  the  labium  majus  and  is  called  a  labial  hernia 
(this  should  not  be  confused  with  a  pudendal  hernia,  p.  800). 

1  Lumbar  hernia  was  first  described  by  J.  L.  Petit  in  1783. 


rso 


HERXIA 


Oblique  Inguinal  Hernia. — Inguinal  hernia  is  more  frequent  in  the 
male  because  of  the  greater  size  of  the  inguinal  canal  and  because  of 
the  existence  of  the  vaginal  process  of  peritoneum  which  accompanies 
the  testicle  in  its  descent  into  the  scrotum.    These  facts  account  also 


Fig.  780. — Incomplete  obliteration  of 
the  funicular  process  of  peritoneum,  just 
above  the  testicle.  Found  at  operation  on 
a  patient  aged  thirty-two  years;  duration 
of  hernia  sixteen  years.  Episcopal  Hos- 
pital. 


Fig.  781. — Ordinary  adult  type  of  in- 
guino-scrotal  hernia:  fundus  of  sac 
separate  from  testicle,  and  easily  enu- 
cleated. Hernia  usually  slowly  de- 
veloped. 


for  the  greater  frequency  of  oblique  than  of  direct  inguinal  hernia. 
It  is  gradually  coming  to  be  recognized,  largely  owing  to  the  teaching 
of  Hamilton  Russell  (since  1899),  and  of  R.  W.  ^Murray,  that  most 


Fig.  782. — Hernia  into  patulous  pro- 
cessus vaginalis:  there  is  no  separate 
tunica  vaginalis.  So-called  "congenital 
hernia. "     A  hernia  of  sudden  formation. 


Fig.  78.3. — Hernia  into  funicular  pro- 
cess: fundus  of  sac  adherent  to  tunica 
vaginalis.  So-called  "infantile  hernia." 
A  hernia  of  sudden  formation. 


cases  of  hernia  are  due  to  the  existence  of  a  preformed  sac.  The  proba- 
bility of  the  existence  of  such  a  sac  is  greatest  in  the  inguinal  region; 
and  formerly  it  was  the  custom  in  describing  oblique  inguinal  hernia 
to  lav  great  stress  on  the  different  varieties  of  sac  which  might  be 


INGUINAL  HERNIA 


781 


present,  aeeordiiig  to  tlie  stage  of  development  which  had  been  reached 
by  the  vaginal  process  of  peritoneum  during  fetal  Hfe.  These  dis- 
tinctions have  little  more  than  academic  interest;  but  a  reference  to 
the  acconii)an\  int,^  illustrations  will  explain  the  five  forms  which  may 
be  encountered.  Occasionally  iiicoiiijjlrir  ohlitenifidn  of  the  Jiininildr 
process  occurs  at  one  or  more  i)oints,  forming  fibrous  bands  or  strictures 
in  the  serous  sac  (Fig.  780) ;  this  accounts  for  cases  of  bilocular  hydro- 
cele (p.  1000),  and  is  of  some  imi)ortance  because  strangulation  may 
occur  at  any  of  these  i)oints,  as  well  as  at  the  neck  of  the  hernial  sac. 
The  fact  of  greatest  imi)ortancc  to  bear  in  mind  is  that  it  is  the  exist- 
ence of  a  preformed  sac  which  predisposes  to  development  of  hernia, 
and  that  it  is  the  extirpation  of  tJie  sac  which  is  the  most  important  step 
(especially  in  cliildren  and  young  adults)  in  the  operation  for  the  cure 
of  hernia.     A.  II.  Ferguson  pointed  out  that  in  some  patients  the 


Fig.  784. — -Hernia  encysted  into  the 
tunica  vaginalis.  The  "encysted  hernia 
of  Sir  Astley  Copper."  Funicular  process 
closed  only  at  the  internal  ring.  An  ac- 
quired hernia  of  slow  formation. 


Fig.  78.5. — Hernia  encysted  between 
tunica  vaginalis  and  testicle.  "Encj^sted 
hernia  of  Hey,  of  Leeds."  Due  to  same 
congenital  defect  as  Fig.  784,  but  parietal 
peritoneum  has  yielded  just  posterior  to 
upper  obliterated  end  of  funicular  process. 


internal  oblique  muscle  does  not  have  an  origin  from  Poupart's 
ligament,  as  is  normally  the  case,  and  that  this  renders  the  region  of 
the  internal  abdominal  ring  very  weak.  Apart  from  these  anatomical 
factors,  the  predisposing  and  exciting  causes  of  inguinal  hernia  are 
the  same  as  those  of  hernia  in  general  (p.  754). 

If  the  hernia  is  present  at  birth  it  is  one  usually  described  as  congenital 
(Fig.  782);  but  of  course  a  "congenital"  sac  may  be  present  but  no 
hernia  develop  until  adult  life.  If  the  hernia  appears  at  any  time 
after  birth,  and  is  of  sudden  formation,  it  is  probable  that  there  was  a 
preformed  sac,  and  that  the  sudden  appearance  of  the  hernia  is  caused 
by  muscular  effort  forcing  some  of  the  abdominal  contents  into  this 
sac  (Fig.  783.)  If  the  hernia  is  of  slow  formation,  which  is  rare  except 
in  adults,  it  is  still  possible  that  a  small  preformed  sac  may  have 
existed. 


782 


HERNIA 


If  the  hernia  occurs  into  a  sac  formed  by  the  patulous  vaginal 
process  of  peritoneum  (Fig.  782),  whether  the  hernia  is  present  at 
birth,  appears  during  infancy  or  childhood,  or  does  not  appear  until 


Fig.  76(5. — Kight  oblique  inguino- 
scrotal  hernia.  Congenital  sac,  but  hernia 
developed  in  adult  life.  Outline  of  testi- 
cle obscured.  (See  Fig.  782.)  Episcopal 
Hospital. 


Fig.  7n7. — Right  oblique  inguino- 
scrotal  hernia,  funicular  type  (infan- 
tile). Age  sixteen  years.  Outline  of 
testicle  distinct  from  that  of  hernia. 
(See  Fig.  783.)    Episcopal  Hospital. 


late  adult  life,  the  contents  of  the  hernia  ivill  obscure  the  outline  of  the 
testicle  (Fig.  786).    If,  however,  the  testicle  has  its  own  tunica  vagi- 


-:^- 


FiG.  788. — Right  oblique  inguino-scrotal  hernia;  age  sixteen  years;  slowly  acquired 
three  years  ago.  McBurney  incision  for  appendicitis  eight  years  ago.  (See  p.  754.) 
Outline  of  testicle  distinct  from  that  of  hernia.  (See  Figs.  781  and  791.)  Episcopal 
Hospital. 


nalis  (Figs.  781  and  783),  the  hernia  and  the  testicle  can  he  perceived  as 
separate  swellings  in  the  scrotum  (Figs.  787  and  788).  This  distinction 
is  of  some  clinical  importance,  when  operative  treatment  is  under- 


INGUINAL  HERNIA  783 

takfii  (\).  "Sltj.  In  all  cast's,  with  wry  tVw  (.'xc('j)ti()iis,  the  hernia  lies 
in  front  of  the  spermatic  cord,  and  even  if  the  hernia  is  irreducible, 
the  cord  usually  can  be  palpated  behind  it. 

Symptoms  and  Diacnosis. — An  ()l)li([U('  in<i;uinal  hernia  is  more 
common  on  the  ri}i;ht  side.  It  appears  first  at  the  internal  abdominal 
riu^,  and  may  or  may  not  descend  into  the  scrotum.  In  its  descent 
it  always  j^asses  through  the  inguinal  canal.  The  longer  its  duration 
and  the  larger  the  hernia,  the  less  oblique  becomes  its  pas.sage 
through  the  abdominal  wall,  as  the  internal  ring  gradually  enlarges 
and  shifts  its  position  nearer  to  the  spine  of  the  pubis.  When  in  the 
scrotum  the  hernia  is  not  attached  to  the  testicle,  and  in  most  cases 
can  be  reduced  within  the  abdomen.  This  reduction  is  attended  by 
characteristic  signs  (p.  757).  If  the  hernia  is  irreducible  the  diagnosis 
may  be  more  difficult;  but  always,  unless  strangulated,  the  hernia 
transmits  an  impulse  when  the  patient  coughs.  The  differential  diag- 
nosis of  direct  inguinal  hernia  is  considered  at  p.  792,  and  that  of 
femoral  hernia  at  p.  794. 

An  incomplete  hujmnaJ  hernia  must  be  distinguished  from:  (1) 
Hydrocele  of  the  cord  (p.  lOGO).  If  this  is  inflamed,  it  may  closel}^ 
resemble  a  strangulated  inguinal  hernia,  unless  a  clear  history  can  be 
obtained.  But  there  are  no  signs  of  intestinal  obstruction.  (2) 
Inflammatory  Lymphadenitis,  or  Inguinal  Bubo  (p.  269),  is  inflam- 
matory in  nature,  is  irreducible;  gives  no  impulse  on  coughing;  and 
usually  a  source  of  infection  in  the  genitals,  lower  extremity,  or  buttocks 
can  be  found.  (3)  Tuberculosis  of  the  Inguinal  Lymph  Nodes  may 
resemble  an  irreducible  epiplocele ;  but  there  is  no  impulse  on  coughing ; 
the  history  of  the  onset  of  the  two  affections  is  different;  the  swelling 
lies  superficial  to  the  inguinal  canal,  and  does  not  extend  into  the 
scrotum  even  if  of  long  duration;  suppuration  is  frequent.  (4)  Cold 
Abscess,  the  result  of  tuberculosis  of  the  spine,  occasionally  makes 
its  appearance  in  the  inguinal  canal ;  it  may  transmit  an  impulse  when 
the  patient  coughs,  and  often  is  reducible  when  he  lies  down;  but  the 
abscess  presents  no  gurgling  on  reduction,  and  it  is  dull  on  percussion, 
which  an  enterocele  is  not ;  moreover,  examination  of  the  spine  usually 
will  reveal  the  true  condition.  (5)  Undescended  Testicle  (p.  1050). 
This  is  recognized  because  the  scrotum  on  the  affected  side  is  empty, 
and  because  of  the  sickening  pain  produced  by  handling  the  tumor, 
which  is  irreducible. 

A  complete  inguinal  hernia  must  be  distinguished  from:  (1)  Vaginal 
Hydrocele,  (p.  1059),  which  appears  first,  not  at  the  internal  abdominal 
ring,  but  in  the  scrotum ;  which  rarely  extends  into  the  inguinal  canal ; 
which  is  attached  to  the  testicle  and  is  irreducible;  which  though  cystic 
on  palpation  is  dull,  not  resonant,  on  percussion,  and  which  transmits 
light.  (2)  Congenital  Hydrocele  (p.  1058);  this  may  be  distinguished 
from  a  hernia  because  the  inguinal  canal  seems  empty  except  for  the 
cord;  because  when  reduction  occurs  there  is  no  gurgling  or  flop  of 
intestine;  because  of  the  extreme  slowness  w'ith  which  the  scrotum 
refills  wdien  the  patient  stands  up;  and  because  the  hydrocele  is  dull 


784 


HERNIA 


on  percussion  and  is  translucent.  (.3)  Varicocele  {\i.  1061).  This 
appears  first  in  the  scrotinn,  not  at  the  internal  abdominal  ring;  it 
may  not  extend  into  the  inguinal  canal;  it  gives  a  xevy  different 
impression  from  a  hernia  when  palpated;  and  though  usually  the 
swelling  disappears  when  the  patient  lies  down  and  the  scrotum  is 
elevated,  this  occurrence  is  not  attended  by  any  of  the  signs  which 
indicate  the  reduction  of  a  hernia.  (4)  Sarcocele  (p.  1056).  This  is 
formed  by  an  enlargement  of  the  testicle  itself;  it  appears  first  in  the 
scrotum;  is  irreducible;  is  dull  on  percussion  even  if  partly  cystic; 
and  though  thickening  of  the  spermatic  cord  may  occur  from  extension 
of  the  disease,  this  does  not  present  the  characteristics  of  a  hernia. 
Oblique  Inguinal  Hernia  in  the  Female. — In  women  only  the  round 
ligament  passes  through  the   inguinal  canal.     It  carries  with  it  a 

process  of  peritoneum  (the  canal  of 
Niick),  which  may  remain  patulous 
and  predisposes  to  the  formation  of 
a  hernia.  The  internal  oblique 
muscle  in  the  female,  as  a  rule, 
has  a  larger  origin  from  Poupart's 
ligament  than  in  the  male,  and  no 
doubt  this  lends  additional  strength 
to  the  region  of  the  internal  ab- 
dominal ring  and  the  inguinal  canal. 
In  children  a  hernia  usually  is  ar- 
rested in  the  canal  of  Nuck  (Fig. 
789),  but  in  adults  it  often  descends 
into  the  labium  majus,  though 
rarely  attaining  very  large  size. 

Strangulation  of    Oblique    Inguinal 

Hernia  may  occur  in  the  neck  of  the 

sac,    at    the    internal    ring,    or    at 

the  external  ring.    The  external  ring 

should  be  divided  first  whenever  strangulation  is  present;  the  sac  is 

then  opened;  and  if  strangulation  is  not  relieved  by  this  means,  the 

neck  of  the  sac  and  the  internal  ring  must  be  divided  also. 

Rare  Forms  of  Oblique  Inguinal  Hernia. — A  hernia  may  make  its 
appearance  at  the  internal  abdominal  ring,  but  for  some  reason  be 
arrested  in  its  journey  downward  to  the  scrotum.  This  may  be  due 
to  the  obstruction  offered  by  an  undescended  testicle  (occasionally 
an  ovary  in  the  female),  or  from  the  partial  constrictions  in  the  lumen 
of  a  preformed  sac,  to  which  reference  was  made  at  p.  781.  (1)  If 
the  hernia  is  arrested  just  outside  of  the  internal  abdominal  ring  and 
forms  for  itself  a  di^'erticulum  out  of  the  sac  wall,  between  the  parietal 
peritoneum  and  the  abdominal  muscles,  it  is  called  an  inguinal  pro- 
per itojieal  hernia  (first  well  described  by  Kronlein  in  1880).  This 
hernia  usually  spreads  toward  the  median  line  of  the  body.  (2)  If 
it  forms  a  sac  for  itself  between  the  muscular  planes  of  the  abdominal 
wall  it  is  called  an  interstitial  or  interparietal  hernia;  this  is  the  least 


Fig.  789. — Double  oblique  inguinal 
hernia  into  the  canal  of  Xuck,  in  a  girl 
of  nine  years.     Children's  Hospital. 


INGUINAL  HERNIA 


785 


unusual  foriu,  and  tlu-  lu-rnia  ^a-ncrally  spreads  outward  toward  tlic 
cTfst  of  tlu'  ilium.  {'A)  If  the  hernia  occupies  a  diverticulum  in  the 
suhcutaneous  tissues,  outside  of  the  external  ahdoniinal  rin^^  upon 
Poupart's  li};ament,  or  overhanging  the  upi)er  i)art  of  Scarpa's  triangle, 
it  is  known  as  a  superficial  inguinal  hernia  or  an  inguinu-crural  hernia; 
this  is  the  rarest  of  these  unusual  forms  of  hernia. 

These  hvTu'nxi  are  very  liable  to  strangulation,  hut  the  exact  diagnosis 
of  the  condition  seldom  is  made  hcfore  operation. 

Unusual  Contents  of  Oblique  Inguinal  Hernia.  The  usual  contenU 
are  small  howel  and  omentum.  The  presence  of  large  bowel  is  unusual. 
When  i)resent  it  usually  forms  what  is  " 
known  as  a  sliding  hernia,  as  the  bowel 
usually  slides  down  retroi)eritoneally, 
carrying  a  peritoneal  pouch  down  with 
it,  covering  only  its  anterior  aspect.  In 
this  pouch  small  bowel  and  omentum 
may  be  contained,  and  when  these  are 
reduced  at  operation,  the  surgeon  will 
find  that  the  posterior  wall  of  the  her- 
nial sac  covers  the  large  bowel  (Fig. 
790).  A  sigmoid  hernia,  occurring  on 
the  left,  is  considered  more  frequent 
than  a  cecal  hernia  on  the  right.  Occa- 
sionally a  cecal  hernia  occurs  on  the 
left;  in  such  cases  it  is  probable  that 
the  cecum  has  been  drawn  into  the  sac 
by  the  traction  of  the  ileum  already  in 
the  sac.  The  presence  of  the  vermi- 
form  appendix  in  the  hernial  sac  is  of 

considerable  importance,  as  it  may  become  the  seat  of  acute  inflam- 
mation, gangrene,  etc.  Such  cases  have  been  carefully  studied  by 
Jacquemin  (1905)  and  by  IMassoulard  (1906).  An  undescended  testicle 
usually  is  accompanied  by  a  hernial  sac;  this  subject  is  discussed  at 
p.  1050.  Occasionally  in  the  female  the  ovary,  the  tube,  or  even  the 
uterus  (pregnant  or  non-pregnant)  is  found  in  the  sac  of  an  inguinal 
hernia;  F.  T.  Andrews  (1905)  has  tabulated  366  cases  of  this  nature. 
Treatment  of  Oblique  Inguinal  Hernia  in  Adults. — A  cure 
without  operation  is  all  but  unknown  in  adult  patients.  The  mor- 
tality  of  the  operation  is  very  low,  scarcely  one  in  three  or  four  hundred 
cases;  and  the  deaths  scarcely  ever  are  due  to  the  operation  itself,  but 
to  complications,  which  may  follow  any  operation.  Recurrence  of 
the  hernia  takes  place  in  very  few  cases;  according  to  Coley,  permanent 
cure  is  effected  by  proper  operation  in  about  95  per  cent,  of  cases. 
But  w^hen  for  any  reason  operation  is  contraindicated,  or  when  the 
patient  refuses  operative  treatment,  the  surgeon  should  know  what 
measure  of  relief  may  be  effected  by  mechanical  treatment,  and  should 
be  able  to  order  intelligently  the  proper  form  of  truss,  and  to  see  that 
it  accomplishes  the  purpose  for  which  it  is  designed. 
50 


Fig.  790. — Slidins  hernia  of  the 
cecum:  small  intestine  in  the  her- 
nial sac.  Age  thirty-one  years; 
duration  two  years.  Episcopal 
Hospital. 


786 


HERNIA 


Trusses  for  hnjuinal  Hernia.- — The  ])ad  of  the  truss  is  to  bo  ap[)lie(l 
over  the  inguinal  canal,  so  as  to  hold  its  superficial  and  deep  walls 
in  contact,  and  thus  to  close  the  channel  by  which  the  hernia  descends. 
The  pad  must  not  be  placed  only  over  the  external  ring,  still  less  over 
the  spine  of  the  pubis,  as  this  allows  the  hernia  to  slide  past  the  truss 
(Fig.  791).  The  pad  should  not  be  set  at  an  angle  with  the  spring  of 
the  truss  (as  in  the  bad  type  of  truss  introduced  in  1837  by  Dr.  Heber 
Chase,  and  still  in  use),  but  should  be  directly  beneath  the  spring,  so 
as  to  ensure  its  remaining  in  place  and  exerting  direct  pressure  on  the 
canal.  The  counterpressure  is  over  the  sacral  region  or  the  pos- 
terior part  of  the  buttock  of  the  opposite  side,  just  lateral  to  the 
posterior  superior  spine  of  the  ilium.  In  young  adults,  where  the 
hernia  is  small  and  easily  retained,  the  cross-body  truss  (Fig.  792)  is 
the  most  serviceable  type.  According  to  De  Garmo  this  type  was 
introduced  by  an   English   firm   of   instrument-makers  toward   the 


Fig.  791. — Badly  fitting  truss  of  French-German  type.  Pad  is  placed  over  spine  of 
pubis,  and  the  hernia  is  now  in  the  scrotum.  Same  patient  as  Fig.  788.  Has  worn 
truss  this  way  more  than  two  years,  in  hope  of  being  cured.    Episcopal  Hospital. 

close  of  the  eighteenth  century.  The  spring  is  complete  in  front; 
beginning  at  the  pad  over  the  inguinal  canal,  it  passes  across  the 
pubis  from  the  affected  to  the  unaffected  side,  and  is  continued  around 
three-fourths  of  the  pelvis  to  the  buttock  of  the  affected  side.  The 
strap  holding  the  ends  of  the  spring  together  thus  lies  on  the  same  side 
of  the  pelvis  as  the  hernia.  The  pressure  made  by  the  pad  is  inward 
and  slightly  upward.  If  the  hernia  is  less  easily  retained,  or  if  the 
patient  is  older  and  obsese,  a  truss  with  double  pads  gives  better  sup- 
port; the  best  is  the  Hood  type  of  truss,  introduced  about  seventy 
years  ago  by  Dr.  J.  W.  Hood,  of  Kentucky.  The  spring  is  solid  in 
front,  and  supports  adjustable  pads,  one  over  each  inguinal  canal 
(Fig.  793),  and  is  continued  posteriorly  on  each  side  to  within  a  few 
inches  of  the  spine,  where  it  is  supplied  with  two  pads  for  counter- 
pressure;  the  ends  of  the  spring  are  connected  across  the  spine  by  a 
short  strap.     This  is  also  the  best  type  of  truss  for  double  inguinal 


INGUINAL  HERNIA 


787 


hernia.  Tlie  truss  is  so  secure  that  very  Httle  elastic  spring'  pressure  is 
neeiled  to  keep  it  in  phice  and  to  retain  tlie  hernia,  a  fact  wiiicli  renders 
it  very  comf()rtal)le  for  tlie  patient  to  wear.  Otlier  forms  of  truss, 
the  English  rat-tail  truss,  and  the  French  and  Ccrnian  trusses  are 
much  less  efficient. 


Fig.  792. — Cross-body  truss,  fitting 
well.  Age  twenty-two  years.  Appen- 
dicitis operation  (rectus  incision)  one 
year  ago;  hernia  developed  six  months 
later.    Episcopal  Hospital. 


Fn,.  7!to. —  Double  hood  truss,  applied 
for  large  left  inguinal  hernia;  light  pad 
also  on  right  side.  Age  fifty-nine  years. 
This  truss  maintains  reduction  even  in 
severe  coughing.     Episcopal  Hospital. 


Operation  for  Oblique  Ixguixal  Hernia. — Almost  every  sur- 
geon who  operates  on  many  cases  of  inguinal  hernia  develops  certain 
modifications  of  technique  peculiar  to  himself.  Many  of  these  have 
been  published  as  original  operations,  though  few  of  them  are  real 
improvements  on  the  universally  accepted  t^pe  of  operation  which  is 
that  introduced  in  1885  by  Bassini.  This  is  the  best  operation  for  the 
average  case,  and  if  it  is  well  learned  the  operator  can  introduce  such 
improvements  as  suggest  themselves  in  special  cases  as  he  increases 
in  experience.  It  is  not  often  that  two  cases  of  hernia  are  as  alike  as 
two  peas. 

Bassini' s  Operation. — ^The  incision  runs  above  and  parallel  to  Pou- 
part's  ligament  from  the  internal  to  the  external  abdominal  ring. 
This  incision  passes  at  once  to  the  aponeurosis  of  the  external  oblique; 
the  deep  layer  of  the  superficial  facia  (Scarpa's  fascia)  sometimes  is 
mistaken  for  this  aponeurosis.  There  will  be  cut  in  this  incision  at 
least  two  veins — the  superficial  epigastric  and  the  superficial  circum- 
flex iliac  veins.  The  four  bleeding-points  should  be  clamped  and 
ligated.  Any  other  bleeding-points  should  be  clamped  and  ligated. 
Every  bleeding-point  encountered  during  the  operation  should  be 
clamped  and  ligated.  It  is  not  suflBcient  to  trust  to  forcipressure  for 
permanent  hemostasis.  The  success  of  the  operation  depends  on  the 
aseptic  healing  of  the  wound,  and  the  development  of  a  very  small 
hematoma  may  nullify  the  entire  work. 


788 


HERNIA 


When  the  aponeurosis  is  exposed,  the  external  abdominal  ring 
should  be  identified.  If  not  readily  apparent  it  is  easily  found  by 
raking  upward  with  the  handle  of  the  scalpel  in  the  neighborhood 
of  the  pubic  spine  (Fig.  794).  An  incision  is  next  made  through  the 
external  oblique  aponeurosis  from  the  region  of  the  internal  ring  into 
the  external  ring;  this  incision  runs  parallel  to  Poupart's  ligament 
and  at  least  half  an  inch  above  it.  Do  not  make  the  incision  too  near 
Poupart's  ligament  or  there  will  be  no  free  margin  of  the  external 
oblique  aponeurosis  to  facilitate  subsequent  suture.  There  is  no 
advantage  in  not  cutting  through  the  pillars  of  the  external  ring. 


Fig.  794. — Operation  for  inguinal  hernia:  superficial  fascia  incised  and  bleeding- 
point.s  located.  Aponeurosis  of  external  oblique  exposed,  and  external  abdominal  ring 
identified  by  handle  of  scalpel. 

^^^len  the  external  oblique  aponeurosis  has  been  incised,  its  cut 
margins  are  retracted,  by  blunt  dissection  with  the  handle  of  the 
scalpel,  until  the  inner  shelving  margin  of  Poupart's  ligament  is  well 
exposed  below,  and  the  arching  fibres  of  the  internal  oblique  can  be 
easily  seen  on  the  upper  (umbilical)  side  of  the  wound.  The  ilio- 
inguinal nerve  should  not  be  injured.  The  index  finger  is  then  passed 
down  on  the  outer  side  of  the  inguinal  canal,  close  to  Poupart's  liga- 
ment, and  hooks  up  all  the  structures  of  the  canal,  including  the 
hernial  sac  and  the  s|>ermatic  cord  (Fig.  795).  By  a  little  skilful  dry 
dissection  the  end  of  the  finger  can  be  passed  entirely  through, 
beneath  these  structures  from  the  lower  to  the  upper  side  of  the 
wound.  Holding  these  structures  upon  the  left  index  finger,  the  sur- 
geon strips  its  various  coverings  off  the  hernial  sac  by  wiping  them 
away  with  gauze  or  by  the  use  of  dissecting  forceps.  As  little  cutting 
as  possible  should  be  done,  as  this  increases'  bleeding.  The  names  of 
these  deep  coverings  of  the  hernia  (intercolumnar  fascia,  i.  e.,  external 
oblique;  cremasteric  fascia,  i.  e.,  internal  oblique,  and  fascia  propria 
i.  e.,  transversalis  fascia,  have   little  more  than   academic   interest. 


INGUINAL  HERNIA 


789 


The  sac  is  least  adlicrcMit  to  surroiiiKliii},^  structures  in  the  upper  part 
of  the  iufiuinal  eaual,  and  it  is  best  to  isuhite  it  here  first. 

When  tlie  sac  is  finally  bared,  it  may  be  opened,  and  its  contents 
reduced.  Then  with  one  fin<;er  inside  the  sac,  the  surj^eon  proceeds 
to  complete  its  enucleation  from  the  surroundinff  tissues.'  The  sac 
sac  is  separated  from  the  cord,  and  the  dissection  is  continued  upward 
to  the  internal  ring,  until  parictdl  pcrituneuni  is  reached.  This  is  known 
by  the  presence  of  pre-peritoneal  fat,  and  by  the  peritoneum  becoming 
whiter,  denser,  and  more  fibrous;  and  the  operator  should  not  be 
satisfied  until  such  peritoneum  has  been  reached.  If  he  desists  before 
parietal  i)erit()neum  is  reached  he  will  leave  the  upper  part  of  the  sac 
behind,  in  the  form  of  a  pouch,  which  will  predispose  to  recurrence. 
The  operation  is  not  always  easy.    When  the  parietal  peritoneum  has 


Fic.  795. — Operation  for  inguinal  hernia:  the  inguinal  canal  has  been  exposed  by 
an  incision  through  the  aponeurosis  of  the  external  oblique.  The  finger  is  passed  down 
close  to  Poupart's  ligament  and  hooks  up  all  the  structures  in  the  canal. 

been  exposed,  the  neck  of  the  sac  is  closed  by  a  purse-string  suture, 
or  if  large  by  continuous  suture,  as  in  the  case  of  any  abdominal  wound. 
It  is  not  sufficient  merely  to  ligate  the  sac  as  one  ligates  an  artery; 
such  a  ligature  is  very  apt  to  slip  off  the  neck  of  the  sac.  When  the 
neck  of  the  sac  has  thus  been  securely  sutured,  the  sac  is  cut  away, 
but  the  ends  of  the  suture  are  left  long;  the  neck  is  now  allowed  to  recede 
into  the  upper  angle  of  the  wound,  and  is  carefully  inspected  for 
bleeding;  if  this  is  found  the  neck  of  the  sac  is  drawn  again  into  full 
view  by  the  attached  suture,  and  the  bleeding-point  is  ligated  or 

1  If  the  sac  is  of  the  "congenital"  type  (Fig.  782),  its  complete  enucleation  is 
impossible.  The  fundus  should  be  left  attached  to  the  testicle,  and  may  be 
sutured,  to  form  a  tunica  vaginalis.  If  very  much  of  the  fundus  is  left  a 
secondary  hydrocele  may  form. 


790 


HERNIA 


controlled  by  an  additional  suture.  When  it  has  been  ascertained  that 
there  is  no  bleeding,  the  ends  of  the  suture  are  cut  short,  and  the 
surgeon  proceeds  to  close  the  inguinal  canal. 

The  spermatic  cord  is  held  out  of  the  way,  and  the  first  row  of  deep 
sutures  is  introduced.  These  sutures  are  to  approximate  the  arching 
fibres  of  the  internal  oblique  and  the  conjoined  tendon  to  the  inner 
shelving  margin  of  Poupart's  ligament,  so  as  to  form  a  new  floor  to 
the  inguinal  canal,  upon  which  the  transplanted  cord  is  to  lie.  This 
is  the  essential  feature  of  Bassini's  operation.  In  passing  these  sutures 
there  is  considerable  danger  of  wounding  the  femoral  vessels,  especially 
the  vein,  beneath  Poupart's  ligament.  These  are  mattress  sutures  of 
chromic  catgut  (No.  2  or  Xo.  3).  The  first  suture  is  passed  at  the 
upper  end  of  the  inguinal  canal  just  below  the  internal  ring.  The 
round-pointed  curved  needle  is  entered  from  the  superficial  aspect  of 


Fig.  796. — Operation  for  inguinal  hernia:  suturing  the  arching  fibres  of  the  internal 
oblique  (beneath  the  cord)  to  Poupart's  ligament. 

Poupart's  ligament  (Fig.  796),  and  emerges  (on  the  surgeon's  index 
finger  as  a  guide)  on  the  deep  and  shelving  border  of  this  ligament 
in  the  inguinal  canal.  It  is  better  to  prick  your  finger  than  to  injiu-e 
the  femoral  vein.  The  needle  is  then  passed  beneath  the  spermatic 
cord,  and  takes  a  firm  hold  of  the  internal  oblique,  passing  through  it 
from  below  upward.  The  course  of  the  needle  is  then  reversed,  passing 
first  through  the  internal  oblique  from  above  downward,  then  across 
the  inguinal  canal  beneath  the  cord,  and  finally  through  Poupart's 
ligament  from  within  outward,  to  emerge  about  half  a  centimeter 
from  its  original  point  of  entrance.  This  completes  the  first  mattress 
suture.  Usually  three  or  four  other  similar  sutures  are  required,  the 
last  sutures  drawing  the  conjoined  tendon  down  against  the  lower 
and  inner  end  of  Poupart's  ligament.  If  the  upper  end  of  the  canal 
seems  weak,   it  is  well  to  pass  the  first  suture  through   Poupart's 


IXariXAL   IIEliSIA 


701 


Iii;;tiiu'iit  and  tlic  iiitcriial  <>l)li(|ii('  just  on  the  lateral  (flank)  side  of  the 
internal  rin^.  By  j)assin,u  all  these  deep  sutures  as  deserihed,  the 
knots  are  hrouulit  entirely  outside  the  inj^Miinal  canal,  'i'his  is  an 
advantajije. 

The  spermatie  cord  is  now  replaced  on  the  superficial  surface  of  the 
internal  ohlifpie,  and  the  cut  niarj^ins  of  the  external  oblique  aponeu- 
rosis are  then  sutured,  over  the  cord,  witli  a  contiiuious  suture  (the 
second  row  of  deep  sutures)  from  above  downward,  leaving  an  opening 
below  (the  new  external  ring)  just  large  enough  to  transmit  the  cord 
(Fig.  7i)7).  The  skin  wound  is  then  closed  in  the  usual  way.  The 
patient  slionld  remain  in  bed  two  weeks,  and  if  the  hernia  was  large, 
or  if  more  than  one  hernia  was  operated  on,  for  three  weeks  or  longer. 


Fig.  797. — Operation  for  inguinal  hernia:  the  aponeurosis  of  the  external  oblique 
is  sutured  over  the  cord. 


In  women  the  operation  is  simpler,  since  there  is  no  cord  in  the  way. 
The  canal  may  be  completel}'  closed,  the  round  ligament  being  included 
in  the  sutures. 

In  infants  the  use  of  a  truss  for  a  year  or  more  will  cure  a  small 
hernia  in  a  fair  proportion  of  cases — De  Garmo  says  in  95  per  cent. 
But  this  means  that  the  truss  fits,  that  it  is  changed  from  time  to  time 
as  the  child  grows,  that  the  patient  is  under  constant  surgical  super- 
vision, and  that  the  truss  is  employed  with  all  the  precautions  enumer- 
ated at  page  759.  Unless  these  conditions  are  fulfilled,  and  they 
rarely  are,  a  cure  need  not  be  expected.  But,  as  a  rule,  it  is  not  desir- 
able, though  perfectly  possible,  to  resort  to  operation  on  a  child  until 
it  has  learned  to  control  its  bladder  and  bowels.  The  youngest  patient 
I  have  operated  on  was  a  boy,  six  weeks  old,  with  strangulated  hernia ; 
he  was  not  confined  to  bed  after  the  operation,  and  did  perfectly  well. 
In  young  children  complete  extirpation  of  the  sac  is  sufficient  to  ensure 
against  recurrence;  it  is  not  necessary  to  transplant  the  cord,  and 
if  it  is  short  it  may  be  impossible  to  do  so.    If  the  inguinal  canal  seems 


792 


HERXIA 


weak,  the  other  steps  of  the  operation  are  the  same  as  in  the  Bassini 
operation.  This  form  of  operation,  without  transplanting  the  cord, 
was  employed  also  in  adults  by  A.  H.  Ferguson  (1899),  and  is  known 
as  Ferguson's  method. 

Direct  Inguinal  Hernia. — This  hernia  is  one  which  protrudes  through 
the  abdominal  wall  on  the  median  side  of  the  deep  epigastric  artery, 
just  to  the  outer  side  of  the  spine  of  the  pubis,  and  directly  behind 
the  external  abdominal  ring.  This  is  the  space  known  as  Hesselbach's 
triangle.  Direct  hernia  is  seen  about  once  in  every  30  to  40  cases  of 
indirect  inguinal  hernia.    It  is  least  rare  in  adults  and  occurs  oftener 

in  men  than  in  women.  It  is 
a  hernia  of  slow  formation, 
and  there  is  no  well  defined 
neck  to  the  sac.  In  most  cases 
it  may  be  recognized  at  a  glance 
(Fig.  798).  Strangulation  is 
very  unusual.  It  is  distin- 
guished from  oblique  inguinal 
hernia  by  the  fact  that  when  it 
has  been  reduced,  pressure  over 
the  internal  abdominal  ring 
does  not  prevent  its  reappear- 
ance. It  should  not  be  for- 
gotten that  a  large  indirect 
inguinoscrotal  hernia  may  cause 
the  position  of  the  internal  ab- 
dominal ring  to  shift  until  it 
lies  directly  behind  the  external 
ring;  but  a  direct  hernia  never 
descends  far  into  the  scrotum. 
Sometimes  when  the  hernia  is  reduced,  it  is  possible  to  palpate  the 
deep  epigastric  artery  on  the  lateral  margin  of  the  hernial  orifice. 
If  there  is  any  doubt  about  the  nature  of  the  hernia,  it  probably 
is  an  indirect  inguinal  hernia. 

A  direct  hernia  usually  protrudes  tlirough  the  conjoined  tendon, 
which  is  carried  forward  as  one  of  its  coverings.  Occasionally,  how- 
ever, it  passes  to  the  outer  side  of  the  conjoined  tendon.  In  most 
cases  the  spermatic  cord  lies  on  the  outer  side  of  the  sac. 

Rare  Forms  of  Direct  Inguinal  Hernia. — Sometimes  the  sac  of  a  direct 
inguinal  hernia  occupies  (1)  a  properitoneal  position  near  the  bladder; 
or  after  protruding  tlirough  the  conjoined  tendon  on  the  median  side 
of  the  obliterated  umbilical  vein,  it  may  lie  (2)  between  the  conjoined 
tendon  and  the  external  oblique  aponeurosis,  or  (3)  in  a  subcutaneous 
position  in  front  of  the  external  oblique  aponeurosis.  For  these  rare 
varieties  of  direct  inguinal  hernia  Reich,  in  1909,  proposed  the  name  of 
Supravesical  Hernia.  He  collected  16  cases  of  the  first  variety,  which 
he  calls  internal  supravesical  hernia;  and  26  cases  of  the  second  and 
third  varieties,  which  he  terms  external  supravesical  hernia. 


Fig.  79S. — Double  direct  inguinal  hernia, 
age  sixty-eight  years;  duration  thirty  j-ears. 
Of  slow  onset,  from  constant  straining  in 
urination.  Has  strictures  of  urethra,  and 
enlarged  prostate.  Operation  on  hemiae 
eontraindicated  until  urinarj-  obstruction  is 
relieved.     Episcopal  Hospital. 


FEMORAL  HERNIA  793 

Treatment  of  Direct  Inguinal  Hernia. — If  a  truss  is  used,  it  must 
ha\o  a  liir^f  i)a(l,  as  the  hernia  is  diflieult  to  eoutrol.  l{ej)air  of  the 
defect  hy  ()i)eration  is  also  more  difhcult  and  is  less  sure  in  preventing 
recurrence  than  in  indirect  inj,minal  liernia.  The  parts  are  exposed 
in  the  same  way,  and  the  sac  is  isolated.  In  doing  this  the  surgeon 
should  remember  that  the  bladder  frequently  protrudes  into  Ilessel- 
baeh's  triangle,  and  that  its  extraperitoneal  surface  is  with  difficulty 
distinguished  from  preperitoneal  fat.  Any  fatty  mass  toward  the 
median  side  of  the  liernial  orifice  should  be  avoided.  When  the  sac 
has  been  opened  and  its  contents  have  been  reduced,  it  will  be  found 
that  an  opening  is  left  which  it  is  difhcult  to  suture  firmly,  owing  to 
the  relaxed  and  atrophied  condition  of  the  various  layers  of  the  afxlomi- 
nal  wall.  After  the  parietal  peritoneum  has  been  sutured,  the  inter- 
nal oblique  and  conjoined  tendon  should  be  drawn  down  if  possible 
and  sutured  to  Poupart's  ligament,  underneath  the  spermatic  cord, 
as  in  the  Bdsshii  operation  (p.  787).  In  cases  where  the  internal 
oblicjue  and  conjoined  tendon  are  very  weak,  the  median  reflected 
flap  of  the  external  oblique  aponeurosis  may  be  included  in  the  sutures 
with  them,  and  be  drawn  down  and  sutured  to  Poupart's  ligament 
beneath  the  spermatic  c6rd;  then  the  lateral  reflected  flap  of  the 
external  oblique  is  sutured  over  the  cord  (E.  WyJlys  Andrews,  1S95). 
If  the  cremaster  is  well  developed  it  may  be  employed  as  an  additional 
layer  in  suturing  the  canal.  Another  plan  may  be  adopted  where 
the  conjoined  tendon  is  so  thin  that  it  will  not  hold  the  sutures;  an 
incision  is  made  through  the  transversalis  fascia  along  the  lateral 
border  of  the  conjoined  tendon,  raising  it  and  the  anterior  sheath  of 
the  rectus  off  this  muscle,  whose  fibres  are  then  drawn  over  and  sutured 
to  Poupart's  ligament  {Bloodgood,  1898).  When,  as  is  often  the  case, 
the  sac  is  blended  with  the  much  relaxed  overlying  structures,  no 
attempt  should  be  made  to  separate  them,  but  G.  G.  Davis's  operation 
(1905)  should  be  employed:  these  blended  tissues  are  divided  trans- 
versely, and  are  overlapped  from  above  downward,  much  as  in  Mayo's 
operation  for  umbilical  hernia  (p.  778).  This  gives  very  satisfactory 
closure.  The  use  of  silver  filigree  or  of  a  free  fascial  flap,  as  noted  at 
p.  774,  may  be  desirable  in  some  cases. 

However  the  deeper  structures  are  sutured,  the  skin  is  closed  in 
the  usual  way,  and  after-treatment  is  conducted  as  after  operations 
for  indirect  inguinal  hernia. 

Femoral  Hernia. — Femoral  or  Crural  Hernia  has  also  been  termed 
merocele.  The  hernia  protrudes  through  the  femoral  canal,  beneath 
Poupart's  ligament,  on  the  median  side  of  the  femoral  vein.  As 
already  noted,  it  is  commoner  in  women  than  in  men,  especially  in 
w^omen  after  the  menopause.  In  childhood  it  is  rare.  Though  in  most 
cases  there  is  a  preformed  sac,  this  may  not  always  be  a  congenital 
deformity,^  but  may  be  a  traction  diverticulum  probably  due  to  the 

1  According  to  Lockwood,  a  congenital  sac  in  the  femoral  canal  is  to  be  attrib- 
uted to  traction  by  aberrant  strands  of  the  gubenernaculum  testis. 


794  HERXIA 

fact  tliat  some  of  the  preperitoneal  fat  is  forcecl  into  the  femoral  canal 
and  gradually  draws  the  peritoneum  after  it.  Such  a  sac  may  exist 
for  many  years  before  a  hernia  forms;  Murray  found  this  condition 
in  48  out  of  200  cadavers.  Most  of  the  femoral  hernice  I  have  seen 
have  been  of  sudden  formation,  clearly  indicatino;  the  previous 
existence  of  a  sac. 

As  the  hernia  develops,  it  carries  before  it  preperitoneal  fat  (septum 
crurale)  and  transversalis  fascia  (crural  sheath).  While  still  in  the 
femoral  canal  it  is  known  as  an  incomplefe  femoral  Jiernia.  Increasing 
in  size,  it  leaves  the  femoral  canal,  causes  bulging  of  the  criijriform 
fascia,  and  curves  upward  over  the  falciform  process  of  fascia  lata,  and 
lies  beneath  the  skin  of  the  groin  {complete  femoral  hernia).  It  seldom 
grows  very  large.  The  only  contents  of  the  sac  often  is  omentum, 
but  neither  this  nor  intestine  is  likely  to  become  irreducible  without 
becoming  at  the  same  instant  strangulated.  Strangulation  probably 
is  more  frequent  in  femoral  than  in  any  other  form  of  hernia,  and 
gangrene  occurs  more  rapidly,  owing  to  the  sharp  margins  of  the 
femoral  canal.  Small  intestine  is  much  more  frequently  present  in 
the  sac  than  the  colon,  but  the  cecum  sometimes  is  found;  A.  C.  Wood 
(190(3)  has  collected  100  cases  in  which  the  \ermiform  appendix  was 
the  only  structure  in  the  sac. 

Rare  Forms  of  Femoral  Hernia. — The  sac  of  a  femoral  hernia  may  have 
one  or  more  diverticula,  and  such  cases  have  been  described  as  sepa- 
rate forms  of  femoral  hernia:  there  are  recognized  (1)  a  diverticulum 
through  the  cribriform  fascia,  or  hernia  of  Hesselbach  (1816);  (2)  a 
diverticulum  through  the  superficial  fascia,  or  hernia  of  Cooper  (1807); 
(3)  a  properitoneal  diverticulum,  or  hernia  of  Tessier  (1834).  A  more 
frequent,  but  still  very  rare  variety,  is  called  a  pectineal  hernia,  or 
hernia  of  Cloquet  (1814);  in  this  the  sac  passes  from  the  femoral  ring 
between  the  pectineus  muscle  and  its  sheath,  instead  of  anterior  to 
the  latter  as  in  the  usual  form;  if  large  the  sac  may  extend  outward 
beneath  the  femoral  vessels.  Ulrichs  (1911)  refers  to  15  cases  of  this 
variety  of  femoral  hernia  which  was  well  studied  in  1907,  by  Dege. 
This  hernia  is  to  be  distinguished  from  another  rare  variety,  in  which 
the  sac  enters  the  sheath  of  the  femoral  vessels,  and  passes  into  the 
thigh  behind  them  (hernia  retrovascularis).  There  have  been  recorded 
also  a  few  cases  of  femoral  hernia  external  to  the  femoral  vessels,  between 
the  ilio-pectineal  ligament  and  the  femoral  artery  (hernia  of  Partridge, 
1846).  A  hernia  through  an  opening  in  Gimbernat's  ligament  was 
described  first  by  Laugier  (1833)  and  is  known  by  his  name;  it  is  on  the 
median  side  of  the  obliterated  umbilical  artery. 

Diagnosis. — A  femoral  hernia  is  to  be. distinguished  from  other  forms 
of  hernia,  from  enlarged  lymph  nodes,  from  subcutaneous  lipoma, 
from  varices  of  the  saphenous  vein,  and  from  psoas  abscess. 

1.  An  inguinal  hernia  appears  first  above  Poupart's  ligament,  and 
can  be  retained  within  the  abdomen,  after  reduction,  by  pressure  over 
the  inguinal  canal.  A  femoral  hernia  always  makes  its  first  appear- 
ance below  Poupart's  ligament,  and  it  will  not  be  retained  within  the 


FEMORAL  HERNIA  795 

abdoinon  if  pressure  is  made  only  over  the  inguinal  canal.  If  the  hernia 
is  irredueihle  the  (hajiiiosis  is  more  (hflicMlt;  hut  if  an  inia|,Mnary  line 
is  drawn  from  tlie  spine  of  the  ])uhis  to  the  anterior  superior  spine  of 
the  ihum,  it  is  safe  to  say  that  a  liernia  wliose  eiiief  hulk  lies  below 
that  line  (which  corresponds  to  Poupart's  ligament)  is  a  femoral 
hernia  (Fiij:.  ~!>5I). 


Fig.  799. — Right  femoral  hernia.     Episcopal  Hospital. 

2.  If  an  obturator  hernia  is  present,  the  femoral  canal  will  be  empty, 
which  is  never  the  case  if  a  femoral  hernia  exists. 

3.  In  femoral  adenitis  the  swelling  may  occur  over  the  femoral  canal, 
but  it  transmits  no  impulse  on  coughing;  moreover,  it  presents  signs 
of  inflammation  and  a  primary  source  of  infection  usually  can  be 
found.  But  as  a  strangulated  femoral  hernia  may  be  present  behind 
inflamed  lymph  nodes,  it  is  safer  to  operate  in  cases  of  doubt.  The 
same  is  true  in  cases  of  fatty  or  other  tumors  overlying  the  femoral  canal. 

4.  A  varicosity  of  the  long  saphenous  vein  may  protrude  over  the 
femoral  canal.  It  transmits  an  impulse  when  the  patient  coughs, 
but  though,  like  a  hernia,  it  disappears  when  the  patient  lies  down, 
its  reduction  is  not  attended  by  gurgling,  nor  when  the  patient  stands 
up  will  its  reappearance  be  prevented  by  pressure  over  the  femoral 
canal. 

5.  A  psoas  abscess  is  secondary  to  tuberculosis  of  the  spine,  which 
usually  may  be  detected  by  proper  examination.  When  the  abscess 
descends  below  Poupart's  ligament  it  usually  appears  on  the  outer 
side  of  the  femoral  vessels.  Though  it  may  transmit  an  impulse  on 
coughing,  and  may  be  reducible,  this  reduction  is  not  attended  bj^  the 
gurgling  so  characteristic  of  hernia. 

Treatment  of  Femoral  Hernia. — The  use  of  a  truss  is  unsatisfactory 
even  in  retaining  the  hernia  within  the  abdomen,  as  it  is  impossible 
to  obliterate  the  femoral  canal ;  the  most  that  a  truss  can  do  is  to  close 
its  lower  (crural)  opening.  No  cure  wdthout  operation  need  be  antici- 
pated; and  in  no  form  of  hernia  is  a  cure  so  necessary,  owing  to  the 
great  frequency  wath  which  strangulation  occurs. 

1.  The  usual  operation  is  done  b}'  the  femoral  route.  The  skin 
incision  may  be  straight,  in  the  long  axis  of  the  body,  directly  over  the 


796 


HERNIA 


femoral  canal,  or  a  flap  may  be  outlined,  convex  outward,  so  that  the 
line  of  skin  sutures  will  be  far  removed  from  the  genitalia  (Fig.  SOO). 
The  incision  should  commence  well  above  Poupart's  ligament,  and 
should  expose  also  the  fascia  lata  and  cribriform  fascia  over  the  upper 
part  of  Scarpa's  triangle.  Care  should  be  taken  not  to  wound  the 
long  saphenous  vein.  When  the  skin  and  subcutaneous  tissues  have 
been  reflected,  the  sharp  margin  of  the  falciform  process  of  the  fascia 
lata  is  to  be  located.  Beneath  this  the  femoral  artery  will  be  felt 
pulsating,  and  to  the  median  side  of  this  is  the  femoral  vein  which  is 
in  constant  danger  of  injury.  On  the  median  side  of  the  wound  the 
surgeon  should  identify  the  pectineus  muscle  and  its  fascia.  Then 
the  sac  may  be  opened.  If  the  hernia  is  large  and  irreducible,  which 
is  seldom  the  case,  it  may  be  impossible  to  identify  these  various 
structures  until  the  sac  has  been  opened  and  its  contents  reduced. 


Fig.  800. — Incision  for  femoral  hernia:     a  a',  for  the  inguinal  method;  b  b',  longi- 
tudinal incision  for  the  crural  method;  c  c',  flap  incision  for  the  crural  method. 

Under  such  circumstances  the  operator  must  cut  down  layer  by  layer 
until  the  sac  is  opened.  It  is  seldom  possible  to  identify  the  various 
coverings  of  the  hernia.  The  omentum  in  an  irreducible  femoral  hernia 
nearly  always  requires  to  be  excised  in  entirety.  When  the  contents 
of  the  sac  have  been  reduced,  the  sac  must  be  traced  up  into  the  femoral 
canal  under  Poupart's  ligament  until  parietal  peritoneum  is  reached. 
This  is  known  by  its  being  whiter,  denser,  and  more  fibrous  than  the 
walls  of  the  hernial  sac.  The  opening  in  the  parietal  peritoneum  is 
then  closed  with  a  purse-string  suture,  and  the  sac  is  cut  away,  with 
the  usual  precautions  against  overlooking  hemorrhage  from  the 
stump  (p.  789).  P>om  recent  observations  (Ochsner)  it  seems  probable 
in  most  cases  of  femoral  hernia,  except  where  the  femoral  canal,  is 
widely  dilated,  that  accurate  suture  of  the  parietal  peritoneum  is  a 
sufficient  preventative  of  recurrence,  even  without  any  attempt  to  close 


FEMORAL  HERNIA  71)7 

tlio  tViiioral  fjiiial  hy  suture.  Hut  in  most  cases  it  is  not  wry  (iiflicuit 
to  insert  one  or  more  sutures  so  as  to  obliterate  the  canal.  The  needle 
(curved  and  round  ])()inted),  threaded  with  cliromic  catj::ut,  is  entered 
on  the  superficial  surface  of  I'oupart's  li«,Mnient,  close  to  the  femoral 
vein,  and  is  made  to  emerge  in  the  femoral  canal,  catching  some  of  the 
fihres  of  the  sheath  of  the  femoral  vein  if  possible  to  do  this  without 
puncturing  the  vein.  The  needle  is  again  gripped  in  the  needle-holder, 
and  is  passed  trans\-crscly  inward,  taking  a  firm  hold  of  the  pectineal 
fascia  and  underlying  muscle,  and  is  again  grii)ped  in  the  needle-iiolder. 
The  needle  is  then  passed  through  Poupart's  ligament  from  below 
upward,  near  its  inner  end,  and  emerges  finally  near  its  original  point 
of  entrance  on  the  superficial  aspect  of  Poupart's  ligament.  This 
completes  the  first  purse-string  suture  of  the  femoral  canal  (Fig.  (SOI). 
If  there  is  room,  a  second  similar  suture  may  be  passed  nearer  the  lower 


Fig.  801. — Crural  operation  for  femoral  hernia:  closing  the  femoral  canal. 


(crural)  orifice  of  the  femoral  canal.  When  these  sutures  are  tied, 
Poupart's  ligament  is  pulled  down  against  the  pectineal  fascia,  and 
the  femoral  canal  is  closed.  The  needle  always  should  be  introduced 
first  on  the  side  of  the  canal  where  the  femoral  vein  lies,  as  there  is 
thus  less  danger  of  injury  to  this  important  structure.  The  skin  wound 
is  then  closed  in  the  usual  \vay. 

2.  The  inguinal  route  for  operation  in  cases  of  femoral  hernia,  intro- 
duced, in  1892,  by  Ruggi,  does  not  seem  to  have  been  employed  much 
in  this  country,  though  it  possesses  many  advantages,  which  I  shall 
mention  after  briefly  describing  the  operation.  The  skin  incision  is  the 
same  as  in  the  operation  for  inguinal  hernia  (Fig.  800,  a  a'),  and  the 
external  oblique  is  divided,  freely  exposing  the  inguinal  canal.  The 
lower  border  of  the  internal  oblique  and  the  conjoined  tendon  (with  the 
spermatic  cord  or  round  ligament)  are  then  pulled  upward  and  toward 


798 


HERXIA 


the  median  line  by  a  retractor,  drawint;  the  transversalis  fascia  tense, 
and  exposing  the  superficial  aspect  of  Hesselbach's  triangle — bounded 
below  by  Poupart's  ligament,  internally  by  the  conjoined  tendon, 
and  on  the  outer  side  by  the  deep  epigastric  artery  (Fig.  802) .     The 


Fig.  802. — Inguinal  operation  for  right  femoral  hernia:  the  aponeurosis  of  the  external 
oblique  has  been  divided,  exposing  the  inguinal  canal.  The  transversalis  fascia  has 
been  divided,  exposing  the  gac  of  the  hernia  entering  the  femoral  ring. 

trans\'ersalis  fascia  is  then  incised  on  the  inner  side  of,  and  parallel 
to,  the  deep  epigastric  vessels.  This  at  once  exposes  the  pouch  of 
peritoneum,  as  it  enters  the  upper  (abdominal)  orifice  of  the  femoral 
canal,  to  form  the  femoral  hernia.  It  lies  just  to  the  median  side  of 
the  external  iliac  vein,  in  full  \iew.  The  hernial  sac  is  then  drawn  out 


Fig.  803. — Inguinal  operation  for  right  femoral  hernia:  the  sac  has  been  removed  and 
the  parietal  peritoneum  sutured;  Poupart's  ligament  is  now  being  sutured  to  Cooper's 
ligament.     Gimbernat's  ligament  in  full  view. 


of  the  femoral  canal,  and  into  the  inguinal  wound.  It  is  opened  and 
its  contents  are  reduced.  It  is  then  easy  to  close  by  suture  the  opening 
in  the  parietal  peritoneum  well  above  the  neck  of  the  sac.  These 
steps  having  been  accomplished,  the  siu"geon  may  insert  a  purse-string 


OBrURATOR  HERNIA  79U 

suture  iu  the  IVnioriil  caual,  precisely  as  in  tlie  erural  method  of 
operation,  except  that  the  steps  of  this  suturing  are  under  better 
control  of  the  eye.  i'oupart's  ligament  is  pulled  down  by  the  sutures 
against  Cooper's  ligament,  firmly  closing  the  femoral  canal  at  its 
abdominal  opening  (Fig.  Hi)'^).  The  internal  oblique  and  conjoined 
tendon  arc  then  allowed  to  fall  back  in  place;  Parlavecchio  and 
Dujarier  suture  them  to  Cooper's  ligament,  over  the  sj)ermatic  cord. 
If  tiu>  inguinal  canal  appears  weak  they  may  be  sutured  beneath  the 
cord  either  to  Cooper's  or  to  Poupart's  ligament.  The  operation  is 
then  concluded,  as  in  cases  of  indirect  inguinal  hernia. 

I  ha\e  cmployetl  this  inguinal  method  for  the  treatment  of  femoral 
hernia  for  a  number  of  years,  and  regard  it  as  superior  in  every  way 
to  the  femoral  route.  It  is  simpler,  easier,  and  I  believe  also  safer. 
In  uncomplicated  cases  it  enables  the  surgeon  to  excise  all  of  the  sac, 
the  whole  of  which  is  readily  drawn  up  into  the  inguinal  w^ound;  and 
it  ensures  closure  of  the  parietal  peritoneum  without  leaving  a  pouch 
which  will  predispose  to  recurrence.  In  complicated  cases  it  gi\'es 
much  freer  exposure  of  the  parts,  and  renders  the  surgeon  master  of 
the  situation:  if  there  is  strangulation,  the  constriction  is  much  more 
readily  found  and  easily  divided;  if  there  is  an  anomalous  distribution 
of  the  obturator  artery,  it  is  easily  discovered,  and  accidental  hemor- 
rhage may  be  promptly-  controlled.;  if  the  gut  is  gangrenous,  and 
intestinal  resection  or  anastomosis  is  required,  these  may  be  done  much 
more  rapidly  and  safely  than  by  the  femoral  method.  By  the  latter 
route  Gim))ernat's  ligament,  the  usual  point  of  constriction,  cannot 
be  divided  under  control  of  the  eye;  it  may  be  impossible,  owing  to 
shortness  of  the  mesentery,  to  draw  down  enough  healthy  bowel  to 
perform  a  resection,  and  even  when  the  anastomosis  is  accomplished, 
if  one  is  required,  it  may  be  impossible  to  return  the  gut  through  the 
narrow  femoral  canal.  The  only  alternative  in  such  cases  is  to  divide 
Poupart's  ligament,  a  procedure  which  renders  recurrence  of  the 
hernia  almost  certain,  and  in  a  form  which  it  is  extremely  difficult 
to  cure.  Should  there  be  a  fecal  abscess  in  the  sac,  however,  it  should 
be  drained  through  a  femoral  incision  before  the  inguinal  operation 
is  begun.  The  peritoneal  cavity  also  should  be  well  protected  by  gauze- 
packs  before  the  gangrenous  gut  is  reduced.  If  it  proves  impossible 
to  draw^  the  sac  up  into  the  inguinal  canal,  its  neck  should  be  opened 
and  its  contents  should  receive  appropriate  treatment.  Under  these 
circumstances  the  fundus  of  the  sac  may  be  allowed  to  remain  in  the 
femoral  canal. 

Obturator  Hernia. — This  is  very  rare.  Berger  found  it  once  among 
10,000  cases  of  hernia.  About  200  cases  are  on  record.  It  is  most  fre- 
quent in  elderly  women.  It  is  a  hernia  of  slow"  formation.  The  sac 
leaves  the  pelvis  through  the  obturator  foramen,  and  protrudes  in 
the  upper  inner  part  of  Scarpa's  triangle,  underneath  the  pectineus 
muscle,  where  the  hernia  can  be  more  easily  felt  than  seen.  The  thigh 
should  be  flexed,  adducted,  and  rotated  slightly  outward:  then  the 
surgeon  places  his  finger  against  the  descending  ranius  of  the  pubis 


800 


HERNIA 


behind  the  addiietor  h)iijiiis,  and  palj)utes  carefully  for  tlie  swelling 
(Maeready).  The  two  limbs  should  be  e()mj)ared.  Sometimes  l)oth 
sides  are  affected.  The  sac  usually  contains  bowel,  but  the  tube  and 
ovary  have  been  present  in  a  few  cases.  The  existence  of  a  hernia 
seldom  is  recognized  until  strangulation  occurs,  and  even  then  the 
true  cause  of  the  symptoms  may  be  overlooked. 

Diagnosis. — The  diagnosis  in  a  case  of  strangulation,  apart  from  the 
symptoms  of  intestinal  ol)struction,  would  depend  on  the  history  of 
previous  attacks  of  incarceration  of  the  hernia,  with  relief  of  pain 
coincident  with  the  sensation  of  something  slipping  back  into  the 
pelvis;  the  onset  of  the  present  symptoms  with  sudden  pain  in  the 
region  of  the  obturator  foramen;  on  the  radiation  of  pain  in  the  dis- 
tribution of  the  obturator  nerve;  and  on  the  discovery  of  a  tender 
swelling  beneath  the  pectineus  muscle,  by  the  mode  of  examination 
already  indicated,  together  with  palpation  of  the  inner  surface  of  the 
obturator  foramen  througli  the  ^'agina  or  rectum. 

Treatment. — Treatment  consists  in  laparotomy  and  reduction  of  the 
hernia,  with  closure  of  the  obturator  canal  by  suture.  The  mortality 
has  been  about  85  per  cent.,  largely  because  the  condition  has  not  been 
recognized  in  time. 


Fig.  804. — Left  pudendal  hernia,  containing  ovary,  in  a  woman  of  eighty  years.     Diag 
nosis  at  operation  (symptoms  of  strangulation).    Recovery.    Episcopal  Hospital. 


Perineal,  Pudendal,  and  Vaginal  Herniae. — These  are  extremely 
rare.  It  is  probable  that  congenital  anomalies  of  the  pelvic  peritoneum 
(possibly  preformed  pouches)  predispose  to  the  development  of  these 
hernise.  They  occur  about  six  times  as  often  in  women  as  in  men. 
In  the  male  the  protrusion  occurs  in  the  perineum  {perineal  hernia), 
between  rectum  and  prostate,  or  rarely  in  the  ischio-rectal  fossa.  It 
may  be  associated  with  prolapse  of  the  rectum.  In  the  female  the 
hernia  may  leave  the  pelvis  behind  or  in  front  of  the  broad  liga- 
ment. In  the  former  case  the  protrusion  may  occur  in  the  perineum, 
in  the  ischio-rectal  fossa,  or  in  the  posterior  vaginal  wall  (vaginal 
hernia).   Vaginal  hernia  usually  is  associated  with  procidentia  uteri.   If 


ISCHIATIC  Hh'RNIA  SOI 

tlic  iKTiiia  loaxc's  11k'  (h'1\  is  in  Iroiit  ol"  tlic  hrdud  lii^aiiiciit,  as  is  more 
ohvu  tlic  case,  it  enters  the  hibiiiiii  majus  {yiidendal  hernia,  Fig.  <S()4), 
wiiere  it  must  he  (listiiij;iiislieil  from  (1)  an  iiiniiiiio-lahial  lieniia, 
which  j)asses  aho\e  tlie  hrim  ol"  the  })el\is,  through  tjic  inj;iiinal  canal; 
and  from  (2)  a  femoral  hernia,  which  also  leaves  the  abdomen  ahoxe 
the  hrim  of  the  pelvis,  and  which  has  the  neck  of  its  sac  external, 
not  internal,  to  the  descen(lin<;'  raimis  of  the  j)uhis. 

Treatment.  -Treatment  usually  is  palliative,  by  the  application  of 
a  suitable  pessary,  T-bandage,  or  other  ai)pliance.  Strangulation  is 
rare.  Operation  is  undertaken  only  wlien  the  hernia  forms  a  com- 
plication of  another  condition,  such  as  prolapse  of  the  rectum,  \agina, 
or  uterus. 

Ischiatic  Hernia. — These  are  also  extremely  rare  forms  of  hernia. 
Koppl  (1!)()8)  has  collected  23  cases.  lie  prefers  Waldeyer's  classifica- 
tion: (1)  Hernia  Ischiadica  Suprapyriformis.  (2)  Hernia  Ischiadica 
Infrapyriformis.  (o)  Hernia  Ischiadica  Spinotuberosa.  The  first  and 
second  forms  occur  througli  the  greater  sacrosciatic  foramen  (11  cases 
above,  and  7  below  the  pyriformis  muscle) ;  the  third  form  (only  one 
case  recorded)  occurs  through  the  lesser  sacrosciatic  foramen.  In  four 
of  the  recorded  cases  the  particular  form  was  not  described. 

These  hernia  occur  into  a  preformed  sac,  either  congenital,  or  formed 
by  the  traction  of  a  gluteal  lipoma,  myxoma,  or  other  tumor.  They 
make  their  external  appearance  along  the  perineal  border  of  the 
gluteus  maximus  muscle,  and  it  is  difficult  to  distinguish  them  from 
perineal  hernia.  If  strangulation  occurs,  the  swelling  should  be 
explored  and  drained  from  below;  then  the  abdomen  should  be  opened, 
and  the  gut  reduced.  The  general  mortality  of  the  reported  cases  is 
34  per  cent. 


51 


CHAPTER   XXII. 

ABDOMINAL  SURGERY  IN  GENERAL,  AND  INJURIES  OE 
THE  ABDO.AIINAL  VISCERA. 

THE  PERITONEUM. 

The  large  serous  sac  known  as  the  j^eritoneum  is  of  immense  impor- 
tance in  surgery.  It  forms  the  omentum  and  mesenteries,  and  covers 
closely  the  gastro-intestinal  tract,  and  less  completely  the  liver,  gall- 
bladder, and  pancreas,  as  well  as  the  spleen,  kidneys,  bladder,  and 
female  organs  of  generation.  Its  total  area  is  said  to  exceed  that  of 
the  skin  which  covers  the  surface  of  the  body.  There  is  present 
normally  a  small  amount  of  fluid,  just  sufficient  to  lubricate  the  endo- 
thelial surfaces.  This  fluid  or  any  extraneous  material  introduced 
into  the  peritoneal  cavity  is  absorbed  largely  in  the  region  of  the 
upper  abdomen,  especially  through  the  peritoneum  lining  the  under 
surface  of  the  diaphragm.  It  is  believed  that  a  constant  upward 
current  exists  from  the  peritoneal  cavity  through  the  diaphragm  to 
the  mediastinal  lymph  nodes;  and  absorption  of  intraperitoneal  exu- 
dates occur  much  more  rapidly  by  this  route  than  through  the  mesen- 
teric lymph  nodes  which  drain  the  mucous  surfaces  of  the  abdominal 
viscera.  Absorption  from  the  peritoneal  cavity  is  hindered  largely  by 
a  faculty  which  the  peritoneum  possesses  in  common  with  all  serous 
membranes — that  of  forming  adhesions.  Advantage  of  this  is  taken 
in  surgery  whenever  any  operative  procedure  becomes  necessary  on 
organs  covered  with  peritoneum.  Isolation  of  an  infected  area  is 
favored  by  the  insertion  of  gauze  packs,  which  will  within  a  few 
days  excite  adhesions  of  sufficient  strength  to  wall  ofl'  the  general 
peritoneal  cavity.  Tlie  slight  mechanical  trauma  inflicted  by 
the  insertion  of  sutures  arouses  sufficient  reaction  in  the  apposed 
serous  surfaces  to  ensure  their  adhesion  if  contact  is  maintained  by 
the  sutures  for  a  week  or  ten  days;  hence  such  sutures  always  are 
inserted  in  such  a  manner  as  to  bring  serous  surfaces  into  contact  with 
each  other.  In  cases  of  infection  of  the  peritoneum  by  bacteria  and 
their  toxins,  the  injury  to  the  endothelial  surface  of  the  peritoneum 
is  sufficient  in  most  cases  to  cause  adhesion  between  adjacent  serous 
surfaces,  and  it  is  in  this  way  that  infectious  processes  are  localized. 
While  this  results  in  encapsulation  of  an  infecting  focus,  it  also 
entails  a  certain  amount  of  impairment  of  function  in  interference 
W'ith  peristalsis. 

Peritonitis. — Inflammation  of  the  peritoneum  is  one  of  the  most 
frequent  abdominal  conditions  met  with  in  surgery.     It  is  caused  by 


PERITONITIS  S()3 

l);K'tori;iI  infection.  Tlie  existence  of  "idiopathic"  i)eritonitis  is  no 
longer  rccounized.  K\-en  if  we  cannot  find  the  ])ortal  of  infection, 
we  can  at  least  identify  the  inicro(")r<^anisnis  which  are  the  nltiinate 
cause  of  the  j)eritonitis;  and  it  may  be  accepted  as  an  axiomatic  truth 
that  in  practice  no  peritonitis  exists  unless  it  has  been  caused  by 
bacteria.  K\))eriinentally  an  asepti(;  peritonitis  may  be  produced  l)y 
the  intraperitoneal  injection  of  irritatin<f  but  sterile  chemicals;  and 
theoretically  when  any  incision  into  the  peritoneal  ca\ity  is  repaired 
the  process  of  union  which  occurs  is  a  form  of  peritonitis;  but  what 
is  understood  by  the  term  peritonitis  standing  alone,  is  a  bacterial 
in  fret  ion  of  thr  prrifonciim. 

Causes. — The  bacteria  and  their  toxins  gain  access  to  the  jxTi- 
toneum  in  various  ways.  (1)  In  the  immense  majority  of  eases 
they  come  from  the  gastro-intestinal  tract,  which  always  is  swarming 
with  bacteria;  these  escape  from  the  intestinal  tract  as  the  result  of 
lesions  which  will  be  studied  in  the  next  chapter  (appendicitis,  intes- 
tinal obstruction,  cholecystitis,  etc.).  (2)  In  a  large  proportion  of 
cases  in  the  female  the  infection  comes  from  the  internal  genitalia. 
(3)  In  a  few  cases  infection  is  carried  from  without  by  injury;  but  in 
these  cases  the  infection  which  results  from  injury  of  the  intraperi- 
toneal organs  is  much  more  serious  than  that  which  is  carried  into  the 
wound  by  the  vulnerating  body.  (4)  In  a  small  proportion  of  cases 
the  infection  is  believed  to  be  hematogenous  in  origin.  (5)  In  excep- 
tional cases  peritonitis  develops  from  extension  of  inflammation  from 
some  focus  in  kidney,  bladder,  diaphragm,  abdominal  wall,  or  other 
neighboring  structure. 

The  microbes  most  frequently  encountered  are  the  staphylococcus, 
streptococcus,  and  colon  bacillus,  in  enterogenous  infections;  the 
gonococcus  and  streptococcus  in  genital  infections;  and  the  tubercle 
bacillus  or  the  pneumococcus  in  those  apparently  of  hematogenous 
origin. 

Pathology. — As  a  rule,  peritonitis  begins  as  a  more  or  less  localized 
process  in  the  immediate  neighborhood  of  the  atrium  of  infection 
whether  this  be  the  vermiform  appendix,  the  gall-bladder,  the  Fallopian 
tube,  an  ulcer  in  the  gastro-intestinal  tract,  or  any  other  lesion  (Plate 
VII,  fig.  1).  Peritonitis  always  is  either  increasing  or  decreasing;  it 
does  not  remain  stationary.  It  is  not  a  state  but  a  process;  it  runs 
a  more  or  less  definite  course,  sometimes  of  infinite  complexity,  owing 
t6  changes,  which  will  be  studied  in  detail  later.  The  disease  pro- 
gresses either  to  recovery  or  to  death  of  the  patient,  as  surely  as  does 
inflammation  of  any  other  structure  in  the  body,  as  pointed  out  in 
Chapter  I.  Its  course  is  so  very  markedly  influenced  by  treatment 
that  this  important  fact  sometimes  is  overlooked. 

The  omentum  plays  a  much  more  conspicuous  part  in  the  process 
of  peritonitis  than  is  generally  recognized.  This  structure  may  be 
regarded  as  an  aggregation  of  phagocytes  enmeshed  in  fat.  The 
endothelial  cells  which  line  its  surface  are  highly  phagocytic.  The 
omentum  is  the  chief  source  of  the  reactive  processes  which  are  aroused 


804  ABDOMINAL  SURGERY  IN  GENERAL 

by  peritoneal  infection.  By  chemotactic  attraction  it  is  drawn  to  the 
point  of  attack,  and  it  envelops  the  infecting  lesion  in  the  endeavor 
to  localize  it.  Other  adjacent  structures  also  become  adherent  to  each 
other.  When  the  peritonitis  has  been  thus  localized  the  further 
progress  of  the  inflaniniation  is  the  same  as  that  which  occurs  else- 
where when  the  protective  forces  are  in  the  ascendant:  the  phagocytes 
accomplish  their  task,  the  bacteria  are  killed  and  their  toxins  neutral- 
ized, and  the  patient  recovers  from  his  attack  of  peritonitis.  Bid 
the  omentum  remains  adherent  to  the  diseased  area;  and  more  or  less 
extensive  intestinal  adhesions  persist.  There  may  or  may  not  be  the 
formation  of  an  abscess  beneath  the  omentum,  or  in  the  midst  of  intes- 
tinal adhesions  (Plate  VII,  fig.  3).  If  one  is  formed,  it  will  run  the 
same  pathological  course  as  an  abscess  in  other  situations;  it  will  tend 
to  point  and  to  rupture  at  the  site  of  least  resistance,  and  this  may  be 
into  the  surrounding  peritoneal  cavity,  into  the  bowel,  bladder,  etc., 
or  rarely  through  the  overlj'ing  abdominal  wall.  The  frequency  and 
great  danger  of  intraperitoneal  rupture  makes  it  incumbent  on  the 
surgeon  to  recognize  and  to  drain  such  an  abscess  as  soon  as  possible. 

If  intraperitoneal  rupture  of  such  an  abscess  is  followed  by  a  slight 
attack  of  peritonitis  only,  which  at  once  becomes  localized  in  the  form 
of  a  second  abscess;  and  if  this  abscess  ruptures  in  turn  and  a  third 
abscess  is  formed,  and  so  on  until  multiple  abscesses  exist,  then  the 
condition  corresponds  to  the  progressive  fibrino-punilent  peritonitis  of 
Mikulicz  (1889).  A  large  part  of  the  peritoneal  cavity  may  be  invaded 
in  this  way,  the  intestines,  omentum,  and  neighboring  structures 
being  matted  together  in  an  inextricable  mass  of  adhesions  among 
which  are  found  numerous  minute  abscesses.    This  occurrence  is  rare. 

If  the  primary  infection  is  very  severe  the  bacterial  toxins  may  be 
diffused  within  the  peritoneal  cavity  before  the  omentum  has  an 
opportunity  to  encapsulate  the  source  of  infection.  Then  you  will 
find  on  opening  the  abdomen  that  the  omentum  appears  to  have 
dissolved  itself  into  an  exudate  which  is  rich  in  anti-bodies  and  which 
on  culture  you  will  often  find  sterile.  The  bacteria  are  enclosed  in 
phagoc}i:es,  or  are  adherent  to  the  omentum,  or  to  the  parietal  or  vis- 
ceral peritoneum.  The  omentum,  as  I  said,  seems  to  be  dissolving  in 
fluid;  it  feels  extremely  slimy,  and  you  cannot  tell  where  omentum 
ceases  and  where  the  fluid  begins;  if  you  hold  the  omentum  up  it  will 
almost  drip  this  fluid  from  its  meshes.  There  are  no  adhesions  any- 
where. Everything  is  covered  by  serous  slime.  This  is  the  stage  of  the 
process  which  is  recognized  as  spreading  or  diffuse  peritonitis  (Plate 
VII,  fig.  2).  The  bowels  are  not  much  altered:  those  nearest  the  seat 
of  disease  may  be  red,  their  lustre  may  be  slightly  diminished,  and 
they  may  even  feel  a  little  sticky;  but  that  is  all.  The  battle  between 
the  attacking  and  repelling  forces  is  as  yet  undecided;  the  process  is 
very  acute,  and  it  changes  with  alarming  rapidity.  This  change 
may  be  either  for  the  worse  or  the  better.  If  the  latter,  then  the 
anti-bodies  gradually  overcome  the  toxins,  evidences  of  systemic 
poisoning  (toxemia)  subside;  the  peritoneal  exudate  becomes  thicker 


PLATE  VII 


Peritonitis. 

1.  Acute  local  peritonitis,  from  appendicitis.     2.  Acute  diffuse  peritonitis.    3.  Single,  primary  abscess. 
4.  General  peritonitis.      5.  Multiple,  residual  abscesses.     (After  de  Quervain.) 


PERITONITIS  805 

and  more  sticky;  lymph  cox  its  the  inllaiiR-(J  intt'stiiics  wliere  their 
endotiieliiil  coverinji;  has  hccn  destroyed;  frank  pus  begins  to  colk'ct 
in  deiKMuK'nt  situations  and  pockets  of  the  jx'ritoneal  ca\ity;  and  as 
th(>  rej)arati\e  process  continues  tlie  infectious  material  is  iocahzed 
in  one  or  many  regions,  wliieli  are  shut  off  from  tlic  rest  of  tlie  peri- 
toneal cavity  l)y  adliesions  between  the  coils  of  intestine,  the  omentum, 
the  parietal  peritoneum,  and  neighboring  structures,  such  as  bladder, 
uterus,  stomach,  gall-bladder,  diaj)hragm,  etc.  The  result  of  such  an 
attack  of  peritonitis  is  the  formation  of  nniltiple  residual  abscesses. 
INIany  surgeons  confuse  this  condition,  which  is  frequent,  with  that 
described  by  Mikulicz  as  progressive  fibrino-i)urulent  peritonitis.  The 
pathogenesis  of  the  latter  form  of  ])eritonitis,  which  is  rare,  has  })een 
described  abo\e;  T  beliexce  the  idea  tliat  it  is  of  fre(iuent  occurrence 
rests  on  faults  of  observation.  Purulent  exudates  collect,  and  residual 
abscesses  form  chiefly  in  the  dependent  portions  of  the  peritoneal 
cavity,  especially  the  pelvis,  the  iliac  fossa,  tJie  lum})ar  gutters,  or  in 
the  subphrenic  regions  (Plate  VII,  fig.  5). 

If  the  resistive  powers  of  the  patient  prove  unequal  to  the  task  of 
localizing  an  attack  of  peritonitis  after  it  has  reached  the  diffuse  stage, 
the  infection  continues  to  spread,  until  what  may  be  called  general 
peritonitis  is  present  (Plate  VII,  fig.  4).  From  this  patients  seldom 
reco^'er.  They  die  of  toxemia  or  septicemia  before  the  invading  forces 
have  been  overcome.  And  if  the  virulence  of  the  infecting  organisms 
is  very  high,  or  if  the  patient's  resistance  is  very  much  below  par,  the 
peritoneal  infection  may  spread  with  alarming  rapidity  from  the  very 
first.  In  such  cases  little  or  no  exudate  is  formed,  but,  on  the  con- 
trary, the  bacterial  poisons  are  c^uickly  absorbed,  and  the  patient  dies 
with  a  dry  peritoneum,  without  adhesions,  without  exudate,  but 
with  the  intestines  red,  friable,  and  on  the  verge  of  disintegration. 
This  usually  is  described  as  septic  peritonitis,  though  the  term  of 
A.  O.  J.  Kelly  (1896),  toxic  peritonitis,  is  preferable.  When  there  is  a 
tendency  for  minute  hemorrhages  to  occur,  either  in  the  subserous 
tissues,  or  free  into  the  peritoneal  cavity,  rendering  the  scanty  exudate 
blood-tinged,  the  condition  is  sometimes  called  hemorrhagic  peritonitis. 

Clinical  Course  and  Diagnosis. — The  symptoms  of  oncoming  peri- 
tonitis are  so  inextricably  bound  up  with  those  of  the  condition  to 
which  it  is  secondary,  such  as  appendicitis,  or  intestinal  perforation, 
that  it  is  difficult  to  distinguish  between  the  two,  especially  as  peri- 
tonitis is  rightly  regarded  not  as  a  distinct  disease,  but  as  itself  a  com- 
plication of  the  underlying  disease.  However,  it  is  convenient  to 
describe  the  clinical  picture  which  a  patient  with  peritonitis  presents 
to  the  observer,  and  then  to  study  more  in  detail  the  physical  signs 
on  which  a  diagnosis  of  peritonitis  is  based. 

Acute  Local  Peritonitis. — The  initial  more  or  less  diffuse  and  colicky 
pain  of  the  primary  lesion  (in  the  appendix.  Fallopian  tube,  gall- 
bladder, etc.)  is  succeeded  within  a  few  hours  by  a  pain  which  is  burn- 
ing, intense,  and  local.  This  is  increased  by  movement,  by  pressure, 
by  coughing,  or  deep  breathing.     The  affected  area  of  the  abdomen 


806  ABDOMINAL  SURGERY  IN  GENERAL 

becomes  extremely  tender,  the  muscles  overlyinj?  it  are  rigid,  peri- 
stalsis is  arrested  in  the  immediate  vicinity  of  the  lesion,  and  there  is 
local  tympany  due  to  paresis  and  distention  of  the  bowel  most  affected 
by  the  peritonitis.  These  factors  account  for  the  persistent  consti- 
pation, and  the  nausea  and  vomiting.  There  is  moderate  elevation  of 
temperature,  leukocytosis,  and  a  raj)id,  hard,  wiry  pulse. 

Acute  Diffuse  Peritonitis. — This  usually  is  a  sequal  to  the  local 
form,  but  in  cases  of  gastric  or  intestinal  perforation  may  exist  from 
the  very  first.  All  the  symptoms  are  aggravated,  and  at  the  onset 
there  often  is  marked  shock.  The  pain  is  almost  unendurable,  con- 
stant, burning,  or  boring,  and  spreads  w^idely  over  the  abdomen.^ 
The  abdomen  is  of  board-like  rigidity. throughout,  and  exquisitely 
tender.  The  patient's  respiration  is  entirely  thoracic,  and  the  flat 
or  even  scaphoid  abdomen  moves  not  at  all,  even  in  deep  inspiration. 
The  patient  lies  on  his  back  or  side,  with  knees  drawn  up  to  relax  the 
abdominal  muscles.  The  constipation  is  absolute;  no  flatus  is  passed; 
peristalsis  is  entirely  absent;  vomiting  is  almost  continuous,  the  patient 
regurgitating  with  little  eft'ort,  every  few  minutes,  small  amounts  of 
offensive  prune-colored  liquid.  The  symptoms  of  this  stage  pass 
almost  imperceptibly  into  those  of  general  peritonitis.  The  evidences 
of  systemic  poisoning  become  pronounced :  there  is  more  fever,  greater 
leukocytosis,  rapid,  shallow  respiration;  the  eye  is  bright,  the  expres- 
sion anxious,  and  the  skin  from  being  rough  and  dry  becomes  covered 
with  a  clammy  moisture.  The  pulse  grows  very  rapid,  running,  weak, 
and  almost  uncountable.  The  abdomen  begins  to  become  distended, 
rigidity  lessens  and  then  disappears;  extreme  distention  finally 
develops.  In  the  last  stages  tenderness  and  leukocytosis  may  be 
absent.  Death  is  preceded  by  delirium,  great  restlessness,  cyanosis, 
air  hunger,  sweating,  subsultus  tendinum,  carphologia,  and  finally 
exhaustion.  In  rare  cases  of  very  severe  infection,  from  the  first, 
and  not  infrequently  before  death,  the  abdomen  is  soft,  and  there  is 
diarrhea   ("septic  diarrhea"). 

The  history  of  the  case  is  of  great  value  in  diagnosing  the  primary 
lesion,  but  in  peritonitis,  as  in  most  other  acute  lesions,  much  more 
reliance  can  be  placed  on  physical  signs  than  on  the  clinical  history  or 
the  symptoms.  It  is  well,  therefore,  to  consider  in  more  detail  some 
of  the  physical  signs  which  were  enumerated  above. 

Rigidity  of  the  Abdominal  IFa//. — This  is  due  to  reflex  (involuntary) 
muscular  contraction,  brought  about  by  stimulation  of  the  spinal 
segments,  whence  arise  both  the  nerves  supplying  the  diseased  abdomi- 
nal viscera  (sympathetic  fibres)  and  those  which  supply  the  over- 
lying muscles  of  the  abdominal  wall.  So  long  as  the  peritonitis  is 
localized,  the  rigidity  wdll  remain  local;  spread  of  rigidity  is  an  indica- 
tion that  the  peritonitis  is  spreading  in  a  similar  manner.     In  some 

1  Peritonitis  limited  to  the  area  occupied  by  the  small  intestine,  and  confined 
beneath  the  omentum,  may  run  its  course  without  any  of  the  usual  symptoms,  so 
long  as  parietal  peritoneum  is  nowhere  affected;  it  is  only  the  parietal  peritoneum 
which  has  pain  sense,  according  to  Lennander,  while  that  covering  the  viscera  is 
insensitive. 


PERITUMTIS  807 

cases  the  stimulus  seems  to  alVect  the  sensory  as  well  as  the  motor 
iierxc  Hlaments  of  the  ahdominal  wall,  and  hyperesthesia  ol"  the  skin 
oxerlyinj;  the  diseased  \iseus  is  present.  (  Onversely,  inexpert  j)alpa- 
tioii  of  the  ahdominal  wall  with  a  eold  hand,  or  with  fin^'ers  lacking 
in  skill  and  jjentleness,  will  stimulate  these  sensory  cutaneous  filaments, 
and  will  cause  contraction  of  the  abdominal  nmscles,  and  thus  may 
make  the  careless  examiner  think  that  rij^idity  flue  to  i)eritonitis  is 
present,  when  he  has  himself  caused  this  rigidity  by  his  inexpert 
examination.  The  true  reflex  rigidity  of  the  abdominal  muscles  can 
be  recognized  only  by  experience,  and  many  physicians  never  learn 
to  recognize  it,  owing  to  inditierence  and  lack  of  practice.  It  is  the 
tadus  cruditufi,  the  experienced  touch,  that  counts,  and  the  only  way  to 
gain  this  experience  is  to  palpate  with  attention  and  care  the  abdomens 
of  hundreds  of  patients  with  and  without  peritonitis. 

Palpation  for  muscular  rigidity  should  be  made  with  the  finger 
ti])s,  but  with  the  utmost  gentleness.  Place  the  ti])s  of  all  four  fingers 
of  both  hands  very  lightly  on  the  surface  of  the  abdomen  at  some 
point  far  rernoved  from  the  region  suspected  of  disease  and  palpate 
the  normal  abdominal  wall  first.  Do  this  gently  and  circumsi)ectly 
in  every  case,  and  you  will  gain  your  patient's  confidence,  and  further 
palpation  will  be  easier.  Having  placed  the  fingers  barely  in  contact 
with  the  abdomen,  arrange  them  so  that  alternate  pressure  wath  each 
hand  will  be  in  a  direction  parallel  to  the  course  of  the  fibres  of  the 
muscle  you  are  about  to  palpate.  Then,  without  at  any  time  raising 
your  fingers  from  the  surface  of  the  abdomen,  and  with  extreme 
gentleness,  bear  down  for  a  fraction  of  a  second  first  with  one  hand 
and  then  witli  the  other.  Repeat  this  manipulation  a  number  of 
times  before  passing  to  another  region  of  the  abdomen,  and  accom- 
plish this  transfer  of  your  hands  without  raising  them  from  the  abdomi- 
nal wall,  so  as  to  spare  the  patient  the  shock  of  a  new  contact.  Having 
reached  another  region,  repeat  your  manipulations  here,  and  so  on 
until  the  entire  abdomen  has  been  covered.  This  should  include  the 
rectus  muscle  of  each  side  both  above  and  below  the  umbilicus,  and 
the  oblique  muscles  not  only  in  the  iliac  and  hypogastric  regions, 
but  in  the  flanks  and  in  the  loins  as  well.  In  this  way  you  will  very 
quickly  learn  the  difterent  sensation  conveyed  to  the  palpating  finger 
by  a  rigid  or  a  normally  relaxed  muscle.  Do  not  be  in  a  hurry,  and 
be  more  gentle  than  you  think  anyone  else  can  be.  This  is  not  at 
all  the  same  kind  of  palpation  that  is  desirable  when  one  is  seeking 
to  discover  a  mass  wdthin  the  abdomen.  It  is  this  latter  form  of 
palpation  that  most  physicians  attempt  when  they  seek  for  rigidity, 
with  the  result  that  they  usually  fail  to  recognize  its  presence.  Here 
the  hand  is  laid  flat  on  the  belly,  and  by  gentle  and  rocking  pressure 
alternately  with  the  heel  of  the  hand  and  the  pulps  of  the  fully  extended 
fingers,  the  examiner  seeks  to  depress  the  abdominal  wall  until  the 
underlying  structures  can  be  palpated. 

If  rigidity  is  present,  it  is  a  clear  indication  that  some  degree  of 
peritonitis  exists.     Slight  rigidity  usually  indicates  a  mild  grade  of 


808  ABDOMIXAL  SURGERY  IX  GENERAL 

peritonitis  so  long  as  the  abdomen  is  not  distended;  and  marked 
rigidity  indicates  peritonitis  of  much  more  serious  import.  So,  too, 
the  extent  of  the  rigidity  on  the  surface  of  the  abdomen  is  a  fair  indi- 
cation of  the  area  of  peritoneum  involved.  But  if  the  patient  is 
excessively  fat,  or  if  the  muscles  are  very  much  atrophied,  no  rigidity 
may  be  palpable. 

Tenderness  on  palpation  is  of  almost  equal  importance  with  rigidity. 
Cutaneous  hyperesthesia,  which  was  referred  to  above,  is  described 
as  superficial  tenderness;  what  is  to  be  studied  now  is  known  as  deep 
tenderness.  When  this  is  exquisite  it  usually  signifies  pus  under  ten- 
sion, whether  the  pus  is  localized  as  an  abscess  or  free  in  the  belly  as 
in  diffuse  peritonitis.  Rigidity  scarcely  ever  is  present  without 
tenderness,  though  the  latter  may  not  be  elicited  by  very  gentle 
palpation  in  the  case  of  a  very  muscular  or  extremely  rigid  abdominal 
wall.  But  tenderness  frequently  persists  after  rigidity  has  given 
way,  as  in  time  it  usually  does,  to  abdominal  distention.  This  per- 
sistence of  tenderness  is  a  very  important  sign,  often  indicating  that 
gangrene  has  occurred  in  the  organ  diseased.  Palpation  through  the 
rectum  often  is  of  great  value,  in  discovering  tenderness  in  the  recto- 
vesical pouch. 

Percussion  of  the  abdominal  wall  should  succeed  palpation.  It 
should  be  done  with  the  utmost  gentleness,  and  not  over  any  area 
which  is  very  tender.  It  is  possible  by  percussion,  much  more  safely 
than  by  palpation,  to  determine  the  presence  of  an  abscess,  or  of  an 
inflammatory  mass  due  to  adherent  omentum.  These  will  give  a 
dull  note  on  percussion,  and  will  be  surrounded  by  areas  of  tympany. 
The  existence  of  an  effusion  which  is  settling  in  the  pelvis  or  the  loins 
may  also  be  ascertained  by  percussion. 

Finally,  auscultation  should  not  be  neglected.  In  cases  of  diffuse 
peritonitis  the  abdomen  is  quiet;  no  peristaltic  sounds  are  heard 
unless  at  a  great  distance  from  the  focus  of  infection. 

Distention  of  the  abdomen  is  a  late  sign  of  peritonitis,  and  of  bad 
prognostic  import.  A  diagnosis  which  is  delayed  until  the  abdomen 
is  distended  is  of  little  use.  The  onset  of  distention  occurs  pari 
passu  with  the  disappearance  of  abdominal  rigidity.  The  distended 
abdomen  may  be  tense  from  tympanites,  but  it  never  is  rigid.  The 
distention  is  the  result  of  two  factors:  the  first  is  paresis  of  the  intes- 
tinal nerves  and  of  those  supplying  the  abdominal  wall,  as  a  result 
of  poisoning  by  the  absorption  of  toxins;  this  relaxes  the  muscular 
tunic  of  the  intestines  and  makes  the  belly  wall  soft.  The  second 
factor  causing  distention  is  the  occurrence  of  fermentative  and  putre- 
factive changes  within  th^  intestines,  producing  tympanites.  The 
constipation  which  has  already  been  noted,  and  the  distention  of  the 
abdomen  which  is  here  discussed,  are  the  consequence  and  not  the 
cause  of  the  patient's  illness.  He  is  not  ill  because  his  abdomen  is 
distended,  but  his  abdomen  is  distended  because  he  is  ill. 

Differential  Diagnosis. — Peritonitis  must  be  distinguished  from  the 
colic  of  acute  gastro-enteritis,  from  pleurisy  and  pneumonia,  and  from 


PERITONITIS  809 

intestinal  obstrnction.  Other  conditions  with  which  it  is  sometimes 
confounded  will  be  discussed  in  connection  with  the  several  lesions 
which  may  cause  peritonitis. 

Acute  (lajitro-rntcritis.— In  mild  cases  this  is  attended  by  sudden, 
sharp,  stabbinjj  pain,  which  varies  in  intensity  from  time  to  time — 
infcstinal  colic.  The  pain  is  relieved  by  pressure  on  the  abdomen. 
There  is  no  tenderness,  no  rigidity,  no  change  in  pulse  or  tempera- 
ture, and  no  leukocytosis.  Vomiting  is  unusual,  but  if  it  occurs  it  is 
not  repeated  when  the  stomach  has  been  emptied.  In  severer  cases 
there  is  vomiting,  and  general  jjbdominal  pain  and  tenderness.  There 
may  be  fever,  with  increase  in  the  pulse  rate,  but  there  is  no  rigidity 
of  the  belly  wall;  and  there  is  diarrhea,  which  is  rare  in  peritonitis. 
In  cases  where  doubt  remains  after  a  thorough  examination,  visit  the 
patient  again  after  an  interval  of  three  or  four  hours,  and  keep  him 
in  constant  surveillance  until  the  nature  of  the  disease  is  manifest. 

Pleurisy  and  pneumonia  often  are  attended  by  pain  referred  to  the 
abdomen,  and  in  children  this  may  be  the  only  complaint.  There  is 
no  nausea  or  vomiting;  only  slight  rigidity  of  the  upper  abdomen, 
and  only  superficial  tenderness  (cutaneous  hyperesthesia)  are  present. 
There  is  no  deep  tentlerness.  If  the  chest  were  examined  in  all  cases 
of  acute  abdominal  disease,  whether  the  presence  of  pulmonary 
complications  be  suspected  or  not,  the  surgeon  would  be  saved  many 
an  error  and  the  patient  an  unnecessary  operation.  Even  if  the  pul- 
monary lesion  is  so  deep-seated  as  to  give  no  distinct  physical  signs,  a 
diagnosis  of  peritonitis  usually  may  be  excluded  by  the  absence  of 
physical  signs  in  the  abdomen,  and  by  the  presence  of  symptoms,  such 
as  rapid  respiration,  dyspnea,  slight  cyanosis,  etc.,  which  are  charac- 
teristic of  thoracic  disease. 

Intestinal  Obstruction  frequently  is  complicated  by  peritonitis  in 
its  later  stages,  just  as  peritonitis  may  be  followed  at  any  time  by 
intestinal  obstruction.  A  differential  diagnosis  often  is  impossible 
when  either  condition  has  existed  for  some  days,  because  then  both 
conditions  may  be  present.  But  at  the  outset  the  two  affections  pre- 
sent very  different  symptoms  and  physical  signs.  In  intestinal 
obstruction,  attentive  study  of  the  patient's  history  usually  will 
reveal  a  cause  for  the  obstruction  in  some  previous  attack  of  peri- 
tonitis. The  attack  of  intestinal  obstruction  begins  with  colick}^  pains, 
and  these  are  more  or  less  relieved  by  pressure  on  the  abdomen. 
The  pain  is  intermittent,  and  between  the  'paroxysms  the  patient  may 
feel  quite  comfortable  and  may  appear  very  well.  In  peritonitis  the 
patient  is  decidedly  ill  from  the  very  commencement  of  the  attack, 
and  there  are  no  remissions.  In  obstruction  the  intervals  between 
the  pains  rapidly  shorten,  but  the  pain  does  not  for  a  long  time  become 
constant;  in  peritonitis  it  is  constant  from  the  beginning.  In  obstruc- 
tion there  is  absolute  constipation,  as  in  peritonitis,  and  no  flatus  is 
passed  by  rectum;  vomiting  occurs  early,  is  persistent,  and  soon 
becomes  of  the  projectile  type  (p.  885),  with  rather  long  intervals 
between  the  attacks  of  vomiting.     In  peritonitis,  on  the  contrary. 


810  ABDOMINAL  SURGERY  IN  GENERAL 

the  patient  vomits  oftener,  the  \'()iiiitus  is  small  in  quantity  each 
time;  and  the  vomiting  is  not  projectile  hut  regurgitant  in  type  (p. 
806).  In  obstruction,  as  in  i)eritonitis,  the  contents  of  the  upper 
bowel  are  vomited  after  the  stomach  has  l)een  emi)tied;  but  in  obstruc- 
tion the  rejected  matters  finally  become  fecal,  wliich  never  is  the  case 
in  peritonitis.  In  obstruction  there  is  no  rigidity  of  the  abdominal 
wall,  and  distention  occurs  early — often  within  a  few  hours.  Rigidity 
is  the  most  \'aluable  early  sign  of  peritonitis,  but  distention  seldom 
occurs  until  after  the  lapse  of  eleven  or  twelve  hours.  The  disten- 
tion of  obstruction  may  at  first  be  localized  to  the  area  immediately 
above  the  obstruction.  Auscultation  in  obstruction  detects  extremely 
active  and  disordered  peristalsis;  sometimes  peristaltic  waves  can  be 
clearly  seen  through  the  distended  belly  wall.  In  peritonitis  the 
abdomen  is  silent.  In  obstruction  the  temperature  is  not  elevated, 
while  in  peritonitis  it  almost  always  is  abo^'e  normal.  Leukocytosis 
is  rare  in  obstruction,  unless  strangulation  has  occurred;  but  in  peri- 
tonitis it  is  the  rule.  In  both  affections  a  steady  increase  in  the  pulse 
rate  occurs,  and  is  a  most  valuable  sign. 

Treatment. — This  is  not  the  place  to  discuss  the  prcAcntion  of  peri- 
tonitis; but  that  it  may  be  prevented  often  by  prompt  operation 
will  be  pointed  out  time  and  again  in  the  following  pages.  What 
concerns  us  here  is  how  to  treat  the  patient  after  peritonitis  has  devel- 
oped; and  I  here  exclude  from  consideration  pelvic  peritonitis  in 
connection  with  gynecological  affections. 

1.  In  the  early  stages,  before  the  peritoneal  inflammation  has  become 
diffuse,  surgeons  are  in  perfect  accord  in  recommending  immediate 
operation,  to  remove  the  source  of  infection,  and  thus  })revent  the 
development  of  diffuse  peritonitis.  This  is  a  much  surer  and  far 
safer  course  to  pursue  than  to  trust  to  the  unaided  powers  of  nature 
to  isolate  and  overcome  the  infection.  If  the  source  of  infection  is  the 
appendix,  it  can  be  entirely  removed;  if  it  is  a  perforation  of  the 
intestine,  it  can  be  sutured,  and  the  further  discharge  of  infectious 
material  prevented;  if  there  is  a  lesion  which  cannot  be  treated  in 
either  of  these  ways  (as  in  acute  pancreatitis)  the  surgeon  can  at  least 
isolate  the  source  of  infection  by  gauze  packs,  providing  drainage,  and 
thus  preventing  further  intra-abdominal  contamination.  The  details 
of  operation,  which  should  be  completed  quickly,  will  be  described  in 
connection  with  the  various  lesions  which  cause  peritonitis. 

2,  When  the  peritonitis  is  in  the  diffuse  stage  surgeons  are  divided 
into  two  camps.  There  are  those  who  think,  with  Ochsner,  that  it  is 
safer  to  undertake  no  operation  in  cases  of  spreading  peritonitis,  but 
to  trust  to  such  measures  as  are  detailed  below  to  aid  nature  in  isolat- 
ing the  infection,  and  to  wait  until  a  residual  abscess  has  been  formed 
before  instituting  drainage.  Neither  Ochsner  nor  anyone  else,  how- 
ever, ever  claimed  that  the  patient  could  be  cured  without  any  opera- 
tion; the  only  question  is  whether  the  operation  shall  be  immediate 
or  postponed.  Then  there  are  other  surgeons  who  believe,  so  long  as 
the  evidences  of  toxemia  are  not  very  marked,  and  so  Jong  as  the 


I'ElilTONITlS  811 

degree  of  (ilxloiiiiiidl  rifiidUji  is  (jreaier  fluin  Us  (listenthnt,  so  loiij;-,  in 
short,  as  it  is  cvidnit  that  th(>  patient  is  still  reacting  to  tin-  inlVction, 
that  throufihout  this  period  it  will  l)e  more  to  the  patient's  ultimate 
advantage  to  institute  drainage  as  soon  as  possible,  and  at  the  same 
time  to  treat  the  foeus  of  infection  by  excision,  suture,  or  tamponade, 
])rovided  this  secondarN'  part  of  the  operation  can  be  carried  through 
without  unduly  prolonging  the  procedure  or  entailing  too  great 
shock.  My  own  belief  and  my  practice,  founded  on  a  not  very  limited 
experience  with  all  forms  of  i)eritonitis,  is  that  operation  under  these 
circumstances  is  not  only  justifiable  l)ut  imperative.  Ochsner  and 
others  limit  the  time  within  which  inun(>diatc  ()i)eration  is  to  be  done 
to  the  first  thirty-six  hours  from  the  beginning  of  the  illness.  Xo 
doubt  this  is  a  convenient  rule  of  thumb,  but  one  patient  will  reach 
at  the  end  of  twelve  hours  a  stage  of  peritonitis  which  will  not  be 
reached  by  another  for  two  or  three  days.  So  that  I  think  it  is  safer 
to  decide  the  question  in  favor  of  or  against  immediate  oi)eration  n()t 
on  the  mere  lapse  of  time,  but,  as  I  have  done  above,  on  the  jxiUcnfs 
physiccd  condiiiou.  Especially  valuable,  I  believe,  is  the  persistence 
of' rigid  it}/  or  the  onset  of  distention.  Statistics  might  be  quoted  to 
support  the  views  of  surgeons  on  both  sides  of  this  question;  but  the 
fallacy  of  trusting  to  such  figures  is  obvious.  Only  those  who  open 
the  abdomen  in  all  these  cases  know  the  state  of  affairs  inside;  those 
who  do  no  operation  give  statistics  founded  on  impressions,  not  on 
visual  inspection  of  the  peritoneum,  and  they  are  quite  as  likely  to 
reckon  as  non-operative  survivals,  patients  whose  peritonitis  never 
became  widespread,  as  the  really  serious  cases. 

.3.  When  diffuse  peritonitis  has  so  far  advanced  that  rigidity  has 
disappeared,  and  marked  distention  is  present,  the  patient  being  ^'ery 
toxic  and  perhaps  delirious,  and  constantly  regurgitating  the  upper 
intestinal  contents,  almost  all  surgeons  are  in  agreement  with  Ochsner 
that  operation  is  more  apt  to  hasten  death  than  to  gi^'e  the  patient 
a  chance  of  recovery.  In  these  cases,  howTver,  a  well  defined  course 
of  treatment  musi  be  pursued,  and  occasionally  even  a  seemingly 
moribund  patient  wull  improve,  one  or  more  abscesses  will  form,  and 
if  these  are  drained  at  a  propitious  time  recovery  may  yet  ensue. 
This  treatment,  about  to  be  described,  is  known  as  the  Ochsner  treat- 
ment of  peritonitis,  because  so  warmly  espoused  by  this  surgeon  ever 
since  1900.  It  should  be  adopted  in  every  case  of  peritonitis  so  soon 
as  the  diagnosis  is  made,  whether  or  not  operation  is  to  be  undertaken. 
If  operation  is  to  be  done,  this  treatment  will  be  of  short  duration, 
but  it  will  aid  materially  in  securing  a  good  result;  and  the  sanie 
treatment  always  is  continued  after  operation  until  the  peritonitis 
subsides.  The'  most  important  features  of  this  non-operative  or 
preparatory  treatment  are:  (1)  abstinence  from  everything  hy  mouth 
(hence  it  sometimes  is  called  "starvation  treatment");  (2)  instillation 
of  fluids  by  the  rectum;  and  (3)  the  head  high  position. 

The  patient  is  placed  in  bed  either  in  Fowler's  position   (1900), 
hing  flat  on  the  back,  and  with  the  head  of  the  bed  raised  twelve 


812 


ABDOMINAL  SURGERY  IN  GENERAL 


to  fifteen  inches  from  the  floor;  or  else  in  the  so-callerl  exa,2;gerated 
Fowler  position,  that  is,  in  a  semi-sitting  posture  in  the  bed  (Fig.  805). 
This  aids  the  gravitation  of  fluids  to  the  pelvis  and  keeps  them  away 
from  the  subphrenic  region,  whence  absorption  is  so  rapid,  thus  dimin- 
ishing toxemia;  and  it  lessens  the  chances  of  ])ulmonary  complications. 
The  patient  is  very  apt  to  slide  down  in  the  bed  unless  supported. 
A  special  chair-like  bed  frame  is  the  best  support,  but  in  emergencies 
a  sand-bag  may  be  passed  beneath  the  mattress  below  the  buttocks, 
or  the  patient  may  sit  in  a  sling  formed  by  tying  the  ends  of  a  sheet 
to  the  two  u])per  posts  of  the  bed. 


Fig.  !S05. — Exaggerated  Fowler  position.  One  week  after  suture  of  a  duodenal  per- 
foration .    Note  slight  elevation  of  reservoir  for  enteroclysis  solution.    Episcopal  Hospital. 

Nothing  ivhatever  is  given  by  mouth,  not  food,  not  water,  not  ice; 
nothing  is  permitted.  Anything  taken  into  the  stomach  rouses  peris- 
talsis, and  this  spreads  infection  more  widely  in  the  peritoneum. 
Moreover,  it  increases  nausea  and  provokes  vomiting.  The  only  thing 
ever  to  be  introduced  into  the  stomach  is  a  stomach  tube,  wiiich 
should  be  used  every  six  hours  or  less  often,  to  relieve  the  stomach  of 
regurgitated  intestinal  contents.  A  patient  who  has  once  experienced 
the  relief  which  lavage  of  the  stomach  affords  under  these  circum- 
stances is  only  too  anxious  to  have  the  procedure  repeated  as  soon  as 
he  feels  his  stomach  refilling. 

To  replace  the  fluids  lost  by  intraperitoneal  effusion,  the  patient  is 
given  saline  solution  or  tap  water  by  the  rectum,  as  already  described 
in  Chapter  V.  This  does  not  excite  peristalsis,  is  quickly  absorbed, 
allays  thirst,  restores  blood-pressure,  dilutes  circulating  toxins,  and 
after  operation  seems  to  promote  drainage  from  the  wound. 

No  drugs  are  required  as  a  rule.  Stimulants,  such  as  camphorated 
oil,  atropin,  digitalis,  or  strychnin,  seldom  are  indicated  and  do  not 
seem  to  have  much  effect.  Mor])hin  very  rarely  is  required;  the  pain 
soon  ceases  if  nothing  is  taken  by  mouth  and  if  nausea  is  controlled 
by  lavage.  Unless  there  is  pain,  sleep  is  not  much  interfered  with. 
But  I  do  not  believe  that  morphin  does  any  harm,  and  there  is  no  reason 
why  it  should  not  be  administered  if  it  promotes  the  patient's  comfort. 

This  treatment  shoiild  he  continued  mitil  the  yeritonitis  subsides. 
This  period  seldom  is  longer  than  three  days,  but  it  may  be  a  week. 


RESIDUAL  PERITONEAL   ABSCESSES  813 

The  more  ahsoliito  the  treatiiieiit  from  tlie  first,  tlie  sooner  will  its 
efl'eet  become  manilest.  I  nder  tliis  form  of  treatment  many  patients 
who  wonld  (He  nnder  any  other  form  of  treatment,  or  after  operation, 
will  survive  the  peritonitis,  and  as  the  abdomen  gradually  softens, 
the  surgeon  will  find  evidences  of  one  or  more  collections  of  pus.  Very 
rarely  a  j)atient  will  recover  from  what  ai)i)ears  to  ha\'e  been  a  diffuse 
septic  peritonitis  without  elfusion;  when  the  abdomen  is  ojx'ned  later 
to  remove  the  cause  of  the  disease,  few  adhesions  and  no  pus  may  be 
foimd.  I  have  seen  only  two  such  cases.  Other  ])atients  will  die  in 
spite  of  this  treatment;  but  it  is  not  too  much  to  say  that  the  Ochsner 
treatment  is  the  only  form  of  treatment  which  gives  these  bad  cases 
of  peritonitis  even  a  fighting  chance. 

After  the  peritonitis  subsides  the  patient  is  still  far  from  convalescent. 
As  the  abdomen  becomes  softer  auscultation  will  detect  commencing 
peristalsis,  and  it  will  be  painless;  flatus  will  be  passed,  and  the  bowels 
may  mo^•e  s|)ontaneously  or  by  simple  enema.  At  this  time  small 
amounts  of  liquid  food  may  be  allowed  by  mouth;  but  if  this 
is  attempted  too  soon  it  will  cause  vomiting,  rouse  active  peristalsis, 
break  up  newly  formed  adhesions,  rupture  an  abscess  which  is  just 
localizing,  and  perhaps  cause  intestinal  obstruction.  The  patient 
must  be  very  carefully  nursed,  and  progress  must  be  sure  rather  than 
rapid.  When  the  abdomen  has  become  entirely  soft  in  parts  removed 
from  the  seat  of  disease,  when  the  bowels  are  acting  normally,  and 
the  patient  is  a])proaching  convalescence,  then  it  is  time  to  drain  the 
abscesses  which  have  formed.  If  these  are  neglected,  and  intraperi- 
toneal rupture  occurs,  the  patient  seldom  survives  even  immediate 
drainage. 

Residual  Peritoneal  Abscesses.  —  So  long  as  an  intraperitoneal 
abscess  is  present,  the  patient  is  in  constant  danger.  No  delay  should 
be  permitted  in  instituting  drainage  when  once  it  is  ascertained  that 
the  patient  can  withstand  the  intervention.  The  abscess  should  be 
incised  and  drained,  if  possible  without  opening  the  uninvolved 
peritoneal  cavity;  nothing  else  should  be  attempted.  Do  not  make 
any  search  for  the  cause  of  the  peritonitis,  but  be  content  to  secure 
drainage.  Make  sure,  however,  that  you  find  all  the  abscesses.  Plate 
VII,  fig.  5,  shows  the  most  frequent  sites  in  which  residual  abscesses 
form.  In  most  cases  a  secondary  and  more  formal  operation  is  indicated 
some  weeks  or  months  later,  to  complete  the  cure  by  removal  of  the 
diseased  organ  (appendix,  gall-bladder),  closure  of  a  fecal  fistula,  etc. 

Pelvic  abscess  sometimes  may  be  drained  by  puncture  through  the 
rectum,  or  through  the  vagina.  Unless  the  anterior  rectal  wall  bulges 
and  fluctuation  is  unmistakable  it  is  safer  usually  to  make  a  supra- 
pubic incision.  This  always  should  be  preferred  when  there  is  also 
an  iliac  abscess;  and  always  after  opening  an  iliac  abscess  the  surgeon 
should  make  sure  that  a  separate  pelvic  abscess  is  not  overlooked. 
A  Ivmbar  abscess  is  drained  by  an  incision  in  the  flank  or  loin. 

Subphrenic  abscess  is  of  great  importance,  because,  though  less 
frequent,  it  is  so  often  overlooked.  It  may  occur  either  (1)  to  the  right 


814  ABDOMINAL  SURGERY  IN  GENERAL 

or  (2)  to  the  left  of  the  falciform  ligament  of  the  liver;  or  (3)  behind 
the  right  coronary  ligament;  or  (4)  in  the  lesser  peritoneal  cavity. 
Abscesses  on  the  extraperitoneal  surfaces  are  rare,  and  usually  are 
secondary  to  hepatic  abscess,  in  connection  with  which  they  are  dis- 
cussed (p.  9o()).  Of  the  four  sites  of  subphrenic  abscess  mentioned 
above,  that  most  frequently  the  seat  of  suppuration  is  the  space 
behind  the  right  coronary  ligament  and  extending  around  its  free 
margin  to  the  subhepatic  space.  Most  abscesses  in  this  situation  are 
secondary  to  appendicitis;  the  abscess  tends  to  point  through  the  lower 
intercostal  spaces,  except  when  intraperitoneal  or  intrapleural  rupture 
occurs.  Most  of  the  abscesses  in  association  with  the  left  lobe  of  the 
liver  in  front  of  the  left  coronary  ligament  are  due  to  gastric  or  duodenal 
lesions;  those  in  the  lesser  peritoneal  cavity  may  follow  gastric  or  pan- 
creatic lesions;  while  those  far  to  the  left  are  rare  and  generally  sec- 
ondary to  splenic  affections  or  are  the  result  of  diffuse  peritonitis. 
The  diagnosis  of  subphrenic  abscess  is  based:  (1)  On  the  history  of  the 
illness,  indicating  a  possible  cause  for  the  formation  of  an  abscess  in 
the  subphrenic  region;  perforated  gastric  or  duodenal  ulcers  cause 
almost  one-third  of  these  cases,  appendicitis  over  one-sixth,  hepatic 
affections  about  one-sixth,  and  the  remaining  one-third  are  due  to 
miscellaneous  affections  (Barnard,  1908).  (2)  On  abdominal  signs  and 
symptoms  of  an  abscess — dulness,  tenderness,  mass,  possibly  rigidity. 
(3)  On  thoracic  signs  and  symptoms,  especially  slight  pleural  frictions 
or  effusion,  or  upward  displacement  of  the  lung  with  increasefl  dulness 
over  the  liver.  (4)  On  general  signs  and  symptoms  of  suppuration — 
fever,  leukocytosis,  chills  and  sweats,  and  especially  progressive 
emaciation.  The  treatment  of  subphrenic  abscess  involves  drainage 
by  operation;  nearly  every  patient  not  operated  on  dies.  In  most 
cases  of  right-sided  abscess  the  operation  is  by  thoracotomy',  as  in 
operations  for  abscess  of  the  liver  (p.  937).  Rarely  an  abdominal 
incision  is  proper.    The  general  mortality  is  about  37  per  cent. 

Peritoneal  Adhesions. — This  condition,  which  has  been  referred 
to  (p.  802),  often  is  described  as  chronic  peritonitis;  it  is  rather  the 
result  of  a  former  peritonitis.  There  is  no  inflammatory  process. 
The  adhesions  which  developed  during  the  existence  of  active  inflam- 
mation remain,  and  by  their  interference  with  peristalsis  cause  symp- 
toms of  which  pain  and  obstipation  are  the  most  constant.  The  drag 
of  adherent  structures  on  the  parietal  peritoneum,  the  mesenteries 
or  the  female  genitalia  may  render  life  miserable,  and  the  patient  may 
become  an  invalid.  Purgation  is  apt  to  rouse  such  acti\'e  peristalsis 
as  to  increase  pain,  and  sometimes  causes  intestinal  obstruction; 
and  the  usual  symptoms  of  coprostasis  are  an  annoyance  unless  the 
bowels  are  opened  normally. 

There  are  other  cases  in  which  peritoneal  adhesions  develop  as  the 
result  of  such  an  attenuated  infection  that  the  origin  of  the  affection 
cannot  be  traced.  Such  are  many  cases  of  Lane's  kink,  of  Jackson's 
membrane,  and  other  forms  of  peritoneal  disease  which  have  been 
recognized  only  within  recent  }ears.    These  are  discussed  at  p.  896. 


TUBERCULOSIS  OF   THE  PERITONEUM  M,') 

The  surgeon  is  powerless  to  prevent  the  formation  of  adlic.^ions  in 
cases  of  acute  peritonitis,  and,  indeed,  often  hails  them  witii  delij,dit 
as  aids  to  tlie  i)atient's  immediate  recovery;  l)Ut  he  is  careful  wlien 
he  opens  tiie  abdomen  in  other  cases  to  avoid  manipulations  wiiich 
will  encourage  the  formation  of  useless  and  disabling  adhesions.  He 
does  not  handle  the  parts  not  concerned  in  the  operation;  he  with- 
draws from  the  abdomen  as  little  of  the  intestine  as  possible,  and 
prevents  it  from  becoming  dried  while  it  is  exposed;  and  he  is  careful 
to  cover  all  denuded  serous  surfaces  by  inversion  with  sero-serous 
sutures  or  by  stitching  the  omentum  over  the  defect.  Various  attempts 
have  been  made  to  j)revent  peritoneal  adhesions  by  the  use  of  oily 
substances,  but  without  much  success.  In  recent  laboratory  work, 
however,  Saxton  Pope  (1914)  has  found  that  a  2  per  cent,  solution  of 
sodium  citrate  in  a  3  per  cent,  (hypertonic)  sodium  chloride  solution 
possesses  great  power  in  preventing  peritoneal  adhesions. 

Treatment. — In  the  treatment  of  peritoneal  adhesions,  it  is  only  by 
experience  that  a  surgeon  can  learn  when  to  let  well-enough  alone. 
If  the  adhesions  are  broken  up  the  new  adhesions  that  form  may  be 
still  more  disabling,  in  spite  of  patient  suturing  and  omental  grafting. 
Unless  the  adhesions  produce  symptoms  it  is  better,  as  a  rule,  not  to 
interfere  with  them.  Of  course,  if  intestinal  obstruction  occurs,  this 
must  be  overcome. 

Pneumococcic  Peritonitis. — This  occurs  oftenest  in  ciiildren,  i)ar- 
ticularly  girls  under  the  age  of  six  years.  ]\Iost  cases  are  secondary 
to  a  pneumococcic  infection  of  the  lungs;  but  the  primary  focus  may 
be  situated  elsewhere,  as  in  the  middle  ear  or  the  female  genitalia. 
The  infection  probably  is  more  often  enterogenous  than  hematogenous. 
The  physical  signs  are  those  of  acute  diffuse  peritonitis  (p.  80(3),  but 
the  patient's  general  condition  is  not  so  much  affected  as  when  the 
peritonitis  is  due  to  the  ordinary  organisms,  and  the  death  rate  is 
much  lower.  In  most  cases  there  is  a  good  deal  of  effusion,  and  this 
usually  becomes  encysted  within  the  course  of  a  few  days  or  a  week. 
It  should  then  be  opened  and  drained. 

Tuberculosis  of  the  Peritoneum. — The  tubercle  bacilli  may  reach 
the  peritoneum  tlirough  the  blood-stream,  from  the  mesenteric  lymph 
nodes,  directly  from  the  intestinal  tract,  or  from  the  Fallopian  tube. 
In  almost  all  cases  there  are  other  tuberculous  lesions  elsewhere  in 
the  body.  Tuberculosis  of  the  lungs  frequently  preexists,  and  in  a 
large  proportion  of  adult  patients  this  will  develop  later  if  not  already 
present  at  the  time  the  signs  of  peritoneal  tuberculosis  are  noted.  As 
a  complication  of  Pott's  disease  of  the  spine,  tuberculosis  of  the 
peritoneum  is  not  very  rare. 

As  a  part  of  a  general  miliary  tuberculosis  (blood  infection),  tuber- 
culosis of  the  peritoneum  has  no  surgical  interest.  The  cases  of  most 
surgical  importance  are  those  in  which  a  removable  focus  of  tuber- 
culosis.exists  in  the  abdominal  cavity.  This  is  most  often  the  Fallo- 
pian iuhe  in  women,  and  the  vermiform  appendix  in  men.  In  children 
tuberculosis  of  the  mesenteric  lymph  nodes  is  more  frequent.     In  many 


816  ABDOMINAL  SURGERY  IN  GENERAL 

cases  a  tuberculous  ulcer  of  the  small  intestine  is  the  point  of  peritoneal 
infection.  Here,  as  in  the  appendix,  the  tubercle  bacilli  penetrate 
the  thinned  floor  of  the  ulcer,  and  usually  without  a  macroscopical 
perforation,  escape  into  the  peritoneal  cavity,  which  becomes  widely 
covered  with  miliary  tubercles.  These  feel  like  minute  shot  or  sand- 
like particles,  projecting  from  the  serous  surfaces.  They  are  yellowish- 
gray  in  color.  The  same  course  of  events  occurs  when  the  infection 
arises  in  the  Fallopian  tube,  whence  it  may  escape  through  the  abdomi- 
nal ostium,  or  by  a  minute  perforation.  It  is  not  improbable  (Baum- 
gartner)  that  the  lesion  is  not  really  primary  in  the  Fallopian  tube, 
but  that  this  has  been  infected  from  its  peritoneal  surface;  but  at  all 
events,  the  tuberculous  process  is  most  active  here  for  the  time  being, 
presumably  because  the  bacilli  have  found  a  fertile  soil  for  develop- 
ment. Tuberculosis  of  a  hernial  sac  is  not  very  rare.  Usually  it  is 
secondary  to  some  intra-abdominal  focus. 

The  changes  in  the  peritoneum  are  those  characteristic  of  other 
forms  of  peritonitis,  only  very  much  milder  in  degree.  Usually  there 
is  a  moderate  amount  of  exudate  formed.  This  may  be  clear,  yellow- 
ish, greenish,  turbid,  or  even  purulent;  not  seldom  it  is  bloody.  When 
the  disease  has  lasted  for  many  months,  adhesions  form,  and  may  be 
very  extensive,  causing  kinks,  and  leading  to  intestinal  obstruction. 
The  omentum  becomes  thickened  and  forms  lumpy  masses  which 
often  can  be  felt  through  the  abdominal  wall.  As  the  omentum  and 
mesentery  both  may  become  retracted  from  thickening  and  tuberculous 
infiltration,  these  masses  usually  are  situated  in  the  left  hypochon- 
drium.  The  intestines  lie  mostly  below  and  to  the  right,  and  their 
tympanitic  state  adds  to  the  distention  of  the  abdomen.  Among  the 
adherent  intestinal  coils  small  collections  of  puruloid  matter  may  occur. 
Rarely  there  is  a  large  encysted  collection  of  fluid.  Caseous  changes 
in  the  mesenteric  lymph  nodes  are  a  late  occurrence.  The  intestinal 
walls  become  very  friable,  and  internal  (entero-enteric)  fistulse  may 
form;  occasionally  an  external  fecal  fistula  develops  spontaneously. 
In  infants  a  tuberculous  abscess  may  discharge  through  the  umbili- 
cus, as  in  a  case  under  my  care  some  years  ago  at  the  Children's 
Hospital. 

Symptoms  and  Diagnosis. — The  disease  is  one  of  early  adult  life, 
and  of  early  childhood.  Before  five  years  of  age  it  is  not  infrequent. 
It  is  rare  after  thirty-five  or  forty  years.  Most  cases  occur  in  women 
between  eighteen  and  thirty  years  of  age. 

Tuberculous  peritonitis  may  begin  rather  acutely,  or  it  may  be 
chronic  from  the  beginning.  In  the  former  case,  after  a  few  weeks  of 
malaise  and  gastro-intestinal  derangements  (colics,  attacks  of  con- 
stipation and  diarrhea,  nausea)  the  first  thing  to  attract  the  patient's 
attention  is  enlargement  of  the  abdomen,  due  to  serous  effusion. 
This  may  persist  unchanged  for  months,  but  usually  there  are  times 
when  the  abdomen  seems  to  become  smaller.  As  time  goes  on,  adhe- 
sions begin  to  form,  and  if  spontaneous  recovery  takes  place  (and  it 
is  not  unknown)  the  abdomen  becomes  softer,  the  bowels  act  normally, 


TUBERCULOSIS  OF   TlIK   I'EIUTONEUM 


817 


the  gciRTal  health  improves,  and  tlie  patient  eonvalesees.  Or  an 
eneysted  coUeetion  of  llnid  may  form,  and  be  cured  by  evacuation. 
In  cases  which  are  chronic  from  the  beginning  the  i)r()dromal 
symptoms  may  have  existed  for  many  montlis;  there  rarely  is  nnich 
ell'usion;  often  none  can  be  detected.  Omental  masses  may  be 
palpabl(\  and  they  may  change  their  site  and  their  form  from  time 
to  time,  in  the  course  of  weeks  or  months,  from  no  appreciable  cause. 
Usually  the  subjective  symptoms  are  slight,  unless  the  adhesions 
cause  intestinal  obstruction,  or  secondary  infection  produces  hectic 
fever.  So  long  as  the  patients  lie  quiet  in  bed  and  are  carefully  nursed 
little  change  in  their  condition  may  be  appreciable  from  month  to 
month  (Fig.  SOO). 


Fig.  sou. — Tuljerculosis  of  the  peritoneum  with  effusion.     Episcopal  Hospital. 

The  diagnosis  of  peritoneal  tuberculosis  will  be  strengthened  by 
finding  any  tuberculous  focus  elsewhere  in  the  body.  Tuberculosis 
of  the  bones  usually  will  be  easily  detected;  but  examination  should 
also  be  made  of  the  lungs,  testicles,  prostate,  seminal  vesicles,  and 
kidneys,  as  incipient  lesions  in  these  structures  often  are  overlooked. 

Treatment. — The  general  hygienic  treatment  already  recommended 
(p.  82)  for  patients  with  tuberculosis  is  most  important  in  cases  of 
tuberculous  peritonitis.  A  fair  proportion  of  cases,  as  pointed  out  by 
Fenger  (1901),  tend  toward  spontaneous  recovery.  If  improvement 
under  general  hygienic  treatment  is  progressive,  no  operation  is  indi- 
cated. In  other  cases,  however,  effusion  persists;  the  patient  does  not 
gain  ground,  and  may  grow  progressively  worse.  In  these  patients, 
the  propriety  of  operative  interference  must  be  considered.  Operation 
has  been  found,  empirically,  to  be  of  most  value  in  cases  with  effusion. 
Tapping  and  aspiration  of  the  fluid  never  have  produced  as  good 
results  as  formal  incision  and  evacuation.  Probably  this  is  for  the 
same  reasons  that  incision  and  evacuation  of  cold  abscesses  in  con- 
nection with  joint  tuberculosis  are  more  successful  than  is  aspiration; 
the  peritoneal  effusion  of  tuberculosis  is  similar  to  a  cold  abscess 
elsewhere,  and  it  is  important  to  prevent  the  occurrence  of  secondary 
infection,  either  from  the  surface  of  the  body  or  from  within  the 
intestinal  tract.  The  abdomen  should  be  opened  in  women,  as  if  for 
an  operation  on  the  uterine  appendages;  in  men,  over  the  appendicular 
region;  as  these  are  the  most  frequent  sites  of  primary  foci.  When- 
ever possible,  without  inflicting  damage  on  the  intestines,  a  tuber- 
52 


818         ABDOMINAL  SURGERY  IN  GENERAL 

culous  appendix  in  men  should  be  removed;  in  women  not  only  should 
one  or  both  tubes  l)e  removed  if  affected,  but  a  diseased  appendix 
also.  If  adhesions  are  present  the  utmost  caution  should  be  used  if 
any  attempts  to  separate  them  are  made.  It  is  very  easy  to  tear  a 
hole  in  the  intestine,  and  very  difficult  to  repair  it.  Even  if  the  intes- 
tinal sutures  can  be  made  to  hold,  union  very  seldom  occurs,  and  a 
fecal  fistula  is  the  nearly  inevitable  result.  Only  if  the  bowel  has  been 
torn  should  the  abdomen  be  drained.  In  other  cases  it  should  be 
closed  tightly,  to  prevent  any  possibility  of  secondary  infection  from 
the  surface  of  the  body. 

In  general  it  may  be  said  that  the  immediate  mortality  following 
operation  is  very  small,  if  proper  precautions  are  taken  against  injuring 
the  intestines.  The  ultimate  prognosis  is  better  when  some  focus  such 
as  the  appendix  or  tube  has  been  removed.  Cure  occurs  much  oftener 
in  the  ascitic  than  in  the  dry  cases.  If  the  patients  are  traced,  nearly 
half  the  number  will  be  found  to  die  within  a  few  years,  and  there 
will  be  many  recurrences.  But  the  prognosis  is  better  with  than  with- 
out operation,  and  even  a  few  years  of  comparative  freedom  from 
discomfort  are  not  to  be  despised. 

OPERATIONS  ON  THE  ABDOMEN. 

Laparotomy,  or  Abdominal  Section,  is  a  general  term  used  to 
describe  any  operation  which  involves  opening  the  peritoneal  cavity.^ 
Definite  operations  are  described  more  accurately  by  specific  names, 
such  as  gastro-enterostomy,  cholecystectomy,  entero-anastomosis,  etc. 
These  terms  will  be  defined  in  the  proper  place.  They  are  sufficiently 
descriptive  of  the  operation  when  they  stand  alone,  and  it  is  not 
necessary  to  complicate  them  by  the  prefix  laparo-  as  is  done  by  some 
surgeons;  though  all  such  operations  include  that  of  laparotomy. 

Abdominal  Incisions. — In  planning  an  incision  through  the  abdomi- 
nal wall,  the  surgeon  must  have  in  mind  not  only  ready  and  sufficient 
exposure  of  the  abdominal  viscera  concerned  in  the  operation,  but  also 
must  endeavor  to  inflict  as  little  injury  as  possible  on  the  structures 
through  which  he  cuts.  There  are  three  things  to  be  considered  in 
this  connection — the  bloodvessels,  the  muscles  with  their  aponeuroses, 
and  the  motor  nerves. 

The  hlood-supply  is  so  free  that  injury  or  ligation  of  any  one  of  the 
main  arterial  trunks  entails  no  danger  of  sloughing;  but  such  injury 
should  be  avoided  whenever  possible  because  time  is  lost  in  checking 
the  hemorrhage,  and  the  wound  is  more  liable  to  become  infected  if 
not  kept  dry.  The  deep  epigastric  artery  is  the  most  important; 
the  superior  epigastric  is  much  smaller;  and  the  deep  circumflex  iliac 
is  not  often  encountered. 

^  Laparotomy  is  derived  from  lairapa  the  Greek  word  for  the  soft  parts  between 
the  ribs  and  pelvis.  Celiotomy  is  used  as  an  equivalent  by  some  writers,  but  is 
considered  less  correct,  as  the  Greek  term  KmAJa  from  which  it  is  derived  was 
used  for  a  cavity  of  any  kind — a  joint,  the  heart,  as  well  as  the  abdomen. 


OPE  RATIONS  ON   THE  ABDOMEN  819 

Muscles  should  1)0  split  in  the  course  of  tlieir  fil)ros  whenever  possible. 
Transverse  section  of  muscle  fibres  is  to  be  avoided;  when  this  is 
unavoidable,  the  muscle  must  be  repaired  by  suture.  The  resulting 
cicatrix  in  the  muscle  will  resemble  one  of  the  lincfe  transversae  in  the 
rectus  abdominis  muscle;  this  will  not  impair  much  the  muscle's  con- 
tractility, but  it  conii)licates  the  operation  and  is  undesirable.  The 
fibres  of  the  tliree  oblique  muscles  of  the  abdomen  cross  each  other's 
course  at  various  angles,  and  transverse  division  of  one  or  two  of  these 
muscles  can  be  avoided  only  in  small  incisions,  such  as  the  grifliron 
incision  of  INIcBurney  (p.  820),  where  each  muscular  layer  is  split 
in  the  direction  of  its  fibres.  Incisions  through  the  rectus  muscle 
can  be  made  of  any  length  by  splitting  its  fibres  parallel  to  their 
course.  An  incision  through  muscular  tissue  is  preferable  to  one 
through  the  linea  alba  or  the  linea  semilunaris,  because  where  several 
layers  of  tissue  are  traversed,  as  in  cutting  through  a  muscle  and  its 
sheath,  much  firmer  union  can  be  secured  by  suturing  the  wound  in 
several  layers,  than  where  only  one  aponeurotic  structure  is  available. 

The  motor  nerves  are  the  most  important  of  all  structures  to  preserve, 
since  they  are  so  small  that  they  cannot  be  sutured  if  cut,  and  the 
muscles  supplied  by  them  are  paralyzed,  and  permit  marked  bulging 
of  the  abdominal  wall  in  spite  of  accurate  repair  of  muscular  and 
aponeurotic  structures  by  suture.  These  nerves  are  branches  of  the 
lower  intercostals  (6th  to  12th)  and  they  run  more  or  less  transversely 
forward  from  the  intercostal  spaces  between  the  transversalis  and 
internal  oblique  muscles,  giving  off  branches  to  these  and  the  external 
oblique;  finally  they  perforate  the  posterior  sheath  of  the  rectus 
muscle  and  supply  it  by  numerous  fine  twigs.  Any  incision  which  will 
divide  these  nerves  is  to  be  avoided  whenever  possible.  An  incision 
through  the  semilunar  line  will  cut  the  nerves  supplying  that  portion 
of  the  rectus  muscle  between  the  incision  and  the  linea  alba.  Hence 
any  longitudinal  incision,  unless  quite  short,  should  be  made  as  near 
the  linea  alba  as  possible.  If  an  incision  is  planned  for  any  other 
part  of  the  abdominal  wall,  it  should,  so  far  as  possible,  run  parallel  to 
and  between  two  of  the  motor  nerves. 

Section  of  nerves,  as  mentioned  above,  results  in  bulging  of  the 
abdominal  wall  from  muscular  paralysis  (Fig.  807).  This  may  entail 
great  disability;  and  unlike  incisional  hernia  (p.  772),  with  which  it 
should  not  be  confused,  it  cannot  be  cured  by  operation.  All  that  can 
be  done  is  to  apply  some  form  of  abdominal  support,  as  in  cases  of 
pendulous  abdomen  (p.  898). 

For  operations  on  the  stomach,  intestines,  and  female  generative 
organs  surgeons  usually  employ  a  longitudinal  incision  splitting  the 
fibres  of  the  rectus  muscle  close  to  the  linea  alba  on  the  right  or  left, 
whichever  appears  to  give  readiest  access  to  the  seat  of  disease.  An 
epigastric  incision  of  course  is  used  in  stomach  operations  (Fig.  808), 
and  one  in  the  hypogastrium  for  pelvic  operations.  For  operations 
on  the  small  intestines  the  incision  usually  is  made  to  the  left  of  the 
median  line,  just  below  the  umbilicus;  thus  it  may  be  extended  upward 


820 


ABDOMINAL  SURGERY  IN  GENERAL 


past  the  umbilicus  without  injuring  the  round  ligament  of  the  liver, 
which  lies  to  the  right. 

For  opnations  on  the  gall-bladder  the  usual  incision  is  a  longitudinal 
one  through  the  outer  third  of  the  right  rectus  muscle,  from  the  costal 
margin  downward  for  four  inches ;  if  more  room  is  needed  the  incision 
is  extended  obliquely  upward  along  the  costal  border  to  the  ensiform 
process  (Mayo  Robson's  ijicmon).  Though  this  incision  necessarily 
divides  a  number  of  motor  nerves  the  resulting  disability  is  much 
less  than  when  an  incision  of  similar  length  is  used  in  the  lower 
abdomen,  where  the  tension  is  greater. 


Fig.  807. — Bulging  of  right  side  of 
abdomen  from  paralysis  of  motor 
nerves  as  result  of  long  incision  in  right 
rectur  muscle.     Episcopal  Hospital. 


Fig.  SOS. — Incision  for  perforated  duo- 
denal ulcer.  Cicatrix  three  and  a  half 
inches.  Suprapubic  stab  wound  for  drain- 
age.    Episcopal  Hospital. 


For  operations  on  the  appendix  a  lateral  incision  is  employed.  If 
only  a  small  incision  is  required,  the  muscle-splitting  or  gridiron  incision, 
introduced  in  1893  by  ]\IcBurney,  is  preferred  by  many  operators.^  It 
is  centred  over  McBurney's  point,  which  is  "from  one  and  a  half  to 
two  inches"  from  the  right  anterior  superior  iliac  spine,  and  on  a 
line  from  that  point  to  the  umbilicus.  The  skin  incision  is  made 
parallel  to  Poupart's  ligament,  and  the  aponeurosis  of  the  external 
oblique  is  divided  in  the  same  direction,  parallel  to  its  fibres.  The 
fibres  of  the  internal  oblique  are  thus  exposed.  They  run  nearly  at 
right  angles  with  the  previous  incision,  and  are  split  in  this  direction. 
The  fibres  of  the  transversalis  at  this  point  run  in  the  same  direction 
as  those  of  the  internal  oblique,  and  are  split  with  them  in  the  direc- 
tion of  their  course.  The  peritoneum  is  opened  by  an  incision 
parallel  to  that  through  the  skin.  This  gridiron  incision  cannot 
well  be  made  more  than  tliree  or  four  inches  long.  ]\Iany  surgeons 
expose  the  appendix  by  a  longitudinal  incision  splitting  the  outer 


*  It  had  been  used  previoush-  by  L.  L.  McArthur. 


OPERATIONS  ON   THE  MihOMEN  .S21 

fibres  of  the  right  rectus  niusele;  tliis  has  been  calleti  Dcaccru  incision; 
he  calls  it  the  "  simple  incision."  Or,  after  opening  the  anterior  sheath 
of  the  rectus  and  displacing  the  fibres  of  this  nniscle  toward  the  median 
line  (passing  around  the  lateral  border  of  the  muscle  without  splitting 
its  fibres),  the  posterior  sheath  of  the  rectus,  together  with  the  trans- 
versalis  fascia  and  peritoneum,  may  be  incised,  as  proposed  by  Battle 
in  ISi)'),  by  Jalaguier  and  by  Kammerer  in  1<S<)7,  and  })y  Ix^nnander  in 
1S*)S.  Both  this  and  Deavcr's  incision  necessarily  divide  a  number 
of  nerves  to  the  rectus  muscle  unless  the  incision  is  short.  For  this 
reason  I  prefer  the  transverse  incision  of  G.  (i.  Davis  (1900),  which 
is  described  at  p.  So4. 

Making  the  Abdominal  Incision. — ^The  skin  and  superficial  fascia  are 
divided  down  to  the  aponeurotic  layer  (external  oblique  aponeurosis, 
anterior  sheath  of  rectus).  Bleeding-points  are  clamped.  The  aponeu- 
rotic layer  is  then  divided  throughout  the  length  of  the  incision.  Do 
not  forget  that  in  the  lower  al)dominal  wall  the  aponeurosis  of  the 
external  oblicjue  does  not  blend  with  the  rectus  sheath  at  the  semilunar 
line,  but  passes  as  a  separate  structure  for  some  distance  toward  the 
meciian  line  before  blending.  Therefore  an  incision  in  the  lower  abdo- 
men just  to  the  median  side  of  the  semi-lunar  line  must  divide  the  exter- 
nal ()l)lique  aponeurosis  and  the  rectus  sheath  as  separate  structures 
before  the  muscular  fibres  of  the  rectus  will  be  exposed.  When  the 
muscular  fibres  are  exposed  they  are  to  be  split  parallel  to  their  course. 
This  is  best  done  by  the  handle  of  the  scalpel,  followed  by  the  fingers 
of  the  surgeon.  In  the  hypogastric  region  the  rectus  fibres  should  be 
split  from  below  upward,  and  in  the  epigastric  region  from  above 
downward,  so  as  in  each  case  to  brush  aside  rather  than  break  oft'  the 
branches  of  the  epigastric  arteries  w^hich  run  in  the  directions  named — 
from  the  epigastrium  down,  and  from  the  hypogastrium  up.  When  the 
transversalis  fascia  and  peritoneum  are  exposed  they  should  be  caught 
up  in  two  hemostats,  applied  about  a  centimeter  apart,  and  should 
be  drawn  away  from  the  underlying  viscera;  then  the  surgeon  should 
divide  these  structures  cautiously,  with  the  flat  (not  the  point)  of  the 
knife,  held  sideways  (Fig.  809).  If  the  peritoneal  cavity  is  not  opened 
at  once,  another  hold  should  be  taken  of  the  intervening  tissues,  and 
thus  the  surgeon  should  cut  dow^n  layer  by  layer  until  the  peritoneum 
has  been  opened.  As  soon  as  this  is  accomplished,  the  scalpel  is  laid 
aside,  and  the  peritoneal  opening  is  enlarged  by  a  blunt  pointed 
scissors  passed  on  the  finger  as  a  guide.  The  peritoneum  is  opened 
to  the  full  length  of  the  abdominal  wound. 

Closing  the  Abdominal  Incision.— The  cut  margins  of  the  peritoneum 
(including  the  transversalis  fascia,  and  where  present  the  posterior 
sheath  of  the  rectus)  are  caught  in  hemostats,  and  drawn  into  the 
wound  until  visible.  The  abdominal  viscera  are  kept  from  protruding 
by  the  insertion  of  a  gauze  pack.  Then  the  peritoneum  is  closed  \yith 
a  continuous  catgut  suture,  applied  so  as  to  evert  the  peritoneum  into 
the  wound  (Fig.  810).  This  brings  endothelial  surfaces  together, 
favors  rapid  union,  and  lessens  the  chances  of  omentum  becoming 


822 


ABDOMINAL  SURGERY  IN  GENERAL 


Fig.  809. — Incising  the  parietal 
peritoneum. 


Fig.  810. — Suturing   parietal  peritoneum 
(Deaver  and  Ashhurst.) 


Fig.  811. — The  "splint  sutures"  have  been  inserted,  and  their  ends  are  clamped.     The 
anterior  sheath  of  the  rectus  is  being  sutured.     (Deaver  and  Ashhurst.) 


OPERATIONS  ON   TIIK  ABDOMEN  S23 

adluTi'iit  to  the  alxloiiiiiiiil  surfiur  ol'  tlu"  cicatrix.     Before  the  hist 
peritoneal  suture  is  drawn  ti^lit,  tlie  gauze  pack  is  removed. 

If  the  wound  is  large  or  if  the  patient  is  very  fat,  several  "relaxa- 
tion" or  "splint  sutures"  are  next  inserted;  these  are  interrupted 
sutures  of  non-ahsorhable  material,  silkworm  gut,  linen,  or  wire. 
Each  splint  suture  is  i)assed  from  the  skin  surface  down  through  all 
structures  of  the  ahdominal  wall  to  the  peritoneum  (which  has  already 
heen  sutured)  across  the  wound,  and  out  through  all  structures  of  the 
ahdominal  wall  on  the  other  side,  to  the  skin  surface.  None  of  these 
sutures  is  tied  at  this  time. 

Next  the  aponeurotic  layer  is  sutured  with  a  continuous  stitch  of 
chromic  catgut  (Fig.  SU ).  The  split  muscle  fibres  fall  together  naturally 
and  do  not  require  a  separate  suture.  If  there  is  much  subcutaneous  fat, 
a  continuous  suture  of  plain  catgut  may  be  used  to  appose  it.  Finally 
the  splint  sutures  are  pulled  taut  and  tied,  not  with  very  much  tension, 
but  just  tight  enough  to  obliterate  all  dead  spaces  in  the  wound.  A 
few  superficial  skin  sutures,  may  be  required  to  secure  accurate  closure. 
If  the  patient  is  not  fat,  and  the  wound  small,  the  splint  sutures  may 
be  omitted. 

In  wounds  which  are  drained  it  is  safer  to  use  interrupted  sutures 
tliroughout,  so  that  should  one  stitch  become  infected  it  may  be 
removed  without  destroying  the  entire  row  of  sutures. 

General  Technique  of  Abdominal  Operations.— There  are  so  many 
technical  points  that  are  common  to  difi'erent  abdominal  operations, 
that  it  is  convenient  to  describe  them  together.  I  shall  consider  here 
preparation  for  operation,  and  after  care;  as  well  as  intestinal  localization, 
methods  of  intestinal  suture,  intestinal  resection,  and  entero-anastomosis. 
In  all  abdominal  operations  the  parts  especially  concerned  in  the 
manipulations  are  walled  off  from  the  rest  of  the  viscera  by  gauze 
"packs"  or  "pads."  These  are  made  by  stitching  together  a  number 
of  layers  of  gauze  (four  to  six  thicknesses  is  sufficient)  so  as  to  give 
the  packs  a  certain  bulk,  and  prevent  ravellings  from  escaping  into 
the  wound.  These  packs  are  made  of  convenient  sizes;  for  a  major 
laparotomy,  they  should  be  about  8  by  14  inches;  for  a  minor  lapa- 
rotomy they  may  be  much  smaller.  Most  important  is  it  not  to  allow 
one  of  the  gauze  packs,  or  a  sponge,  or  an  instrument,  to^  become  lost 
in  the  wound.  Such  accidents  sometimes  occur,  but  with  care  and 
system  are  avoidable  in  almost  all  cases.  It  is  best  to  have  a  tape 
attached  to  one  corner  of  each  pack,  and  to  leave  this  tape  hanging  out 
of  the  wound,  clamped  by  a  hemostat;  if  a  piece  of  gauze  never  is  placed 
entirely  within  the  abdomen,  it  is  not  likely  that  it  will  slip  in  unper- 
ceived.  Some  operators  employ  a  continuous  roll  of  gauze,  which  is 
unrolled  only  as  it  is  inserted  into  the  abdomen.  Many  surgeons  use 
these  packs,  and  all  gauze  employed  within  the  abdomen,  only  after 
it  has  been  moistened  in  hot  saline  solution.  I  prefer  to  keep  them  dry. 
Preparation  of  Patient  for  Abdominal  Operation. — Unless  immediate 
operation  is  demanded,  as  in  emergency  cases,  the  preparation  of  the 
patient  should  begin  at  least  twenty-four  hours  before  the  time  set 


824 


ABDOMINAL  SURGERY  IX  GENERAL 


for  the  operation.  It  is  well  that  he  should  learn  to  pass  his  urine 
while  lying  on  the  flat  of  his  hack  (Atlee);  it  may  save  him  much  dis- 
comfort after  operation.  Other  general  preparation  is  the  same  as 
for  any  major  operation.  The  intestinal  tract  should  be  well  cleared 
by  a  purge  and  this  should  be  administered  sufficiently  early  on  the 
day  before  the  operation  for  it  to  act  before  night,  so  that  the  patient's 
sleep  may  not  be  disturbed.  On  the  day  of  operation,  and  at  least 
two  hours  before  the  time  set  for  operation,  the  patient  should  be 
given  an  enema  of  warm  soapsuds.  Even  in  emergency  cases  it  often 
is  well  to  administer  an  enema  just  before  operation. 


Fig.  812. — Gauze  packs,  for  a  major  laparotomy;  with  "sponge  forceps." 


The  abdomen  should  be  shaved,  including  tlie  pubic  hair,  and  should 
be  washed  ^ith  green  soap,  rubbed  with  alcohol  (GO  per  cent.),  and  with 
bichlorid  of  mercury  (1  to  2000).  Tlien  a  dry  sterile  dressing  should  be 
applied.  This  preparation  is  best  done  in  the  evening  of  the  day  before 
operation;  unless  done  at  least  three  or  four  hours  before  operation,  the 
skin  will  not  be  sufficiently  dry  at  the  time  of  operation  for  the  use  of 
iodin  to  be  effectual  (p.  141).  If  iodin  is  not  used,  the  entire  abdomen 
should  be  washed  again,  after  the  patient  is  etherized,  as  at  the  first 
preparation.  In  emergencies  it  is  suflBcient  to  paint  the  abdomen 
(previously  shaved  dry)  with  3  per  cent,  iodin  twice,  allowing  the 
first  coat  of  iodin  solution  to  become  thoroughly  dried  before  the  second 
is  applied  and  waiting  until  the  second  has  dried  before  making  the 
incision. 

On  the  evening  before  operation  the  patient  should  eat  only  a 
light,  semi-solid  meal  Only  cooked  (sterile)  food  should  be  taken  for 
at  least  two  days  before  operation.    The  mouth  and  teeth  should  be 


OPERATIONS  ON   THE  ABDOMEN  825 

carefully  cleansed.  On  the  day  of  operation  notliinj^  hut  water  sliould 
he  allowed,  unless  the  operation  is  to  he  late  in  the  afternoon.  Then 
a  little  li(iuid,  preferahly  not  milk,  should  he  j^iven  for  hreakfast. 
\Yater  may  he  taken  until  two  hours  hefore  operation,  hut  not  in 
excessive  quantities. 

After-treatment  in  Abdominal  Operations. — \'er>'  little  except  careful 
nursing  is  required  in  uncoinpHc-ated  eases.  If  there  is  no  vomiting, 
a  drachm  of  hot  water  (not  luke-warm)  may  he  given  every  few 
minutes  after  eight  to  twelve  hours.  I  am  quite  convinced  that 
really  hot  water  is  less  apt  to  cause  nausea  than  is  ice  or  ice-water. 
After  eighteen  to  twenty-four  hours  small  cpiantities  of  liquid  diet 
may  be  given;  soft  diet  may  he  l>egun  on  the  third  or  fourth  day. 
If  the  stomach  has  been  the  seat  of  operation  mouth-feeding  should 
not  be  begun  for  from  twenty-four  to  thirty-sLx  hours  after  operation. 
Vomiting  is  treated  by  total  abstinence  from  mouth-feeding;  by 
sitting  the  patient  up  in  bed;  by  the  administration  of  a  glass  of  hot 
water;  and  finally  by  lavage.  The  treatment  of  peritonitis  has  already 
been  considered  (p.  810). 

The  surgeon  should  not  be  in  too  great  a  hurry  to  have  the  patient's 
bowels  moved.  Unless  they  move  spontaneously,  an  enema  may  be 
given  on  the  third  or  fourth  day.  Owing  to  the  pre-operative  catharsis, 
and  the  abstinence  from  food  after  operation,  it  is  futile  to  expect  a 
free  evacuation  any  sooner.  Cathartics  should  not  be  given  after 
operation  unless  the  enema  proves  ineffectual.  Calomel  in  divided 
doses,  followed  by  a  saline  purge,  usually  is  preferred. 

The  patient  may  be  turned  on  his  side  (this  does  not  mean  that  he 
may  turn  himself)  on  the  second  day  after  operation  if  he  desires  it. 
He  should  be  made  comfortable.  If  there  is  peritonitis  he  w^ill  be  in 
the  sitting  posture  (Fig.  805)  and  will  not  need  to  be  turned  over  to 
ease  his  back. 

It  is  not  well  for  the  patient  to  leave  bed  until  several  days  after 
the  sutures  have  been  removed.  Rarely  should  an  abdominal  patient 
spend  less  than  two  weeks  in  bed.  If  the  incision  was  large,  or  the 
operation  very  extensive,  it  may  be  advisable  for  the  patient  to  remain 
in  bed  three  weeks  or  longer.  Only  the  very  old  should  be  hurried 
out  of  bed;  and  even  they,  if  they  can  be  made  comfortable  in  a  sitting 
position  in  bed,  do  just  as  well  in  bed  as  in  a  chair. 

Intestinal  Localization. — Often  during  the  course  of  an  abdominal 
operation  it  becomes  important  to  distinguish  large  from  small  bowel, 
or  even  to  identify  more  or  less  accurately  different  areas  of  the  latter 
as  belonging  to  the  upper  jejunum,  the  middle  of  the  small  gut,  or 
the  lower  ileum.  In  cases  of  peritonitis  or  intestinal  obstruction,  the 
small  intestine  may  be  so  distended  as  to  equal  or  exceed  the  size  of 
the  colon,  so  that  mere  size  is  no  criterion.  In  many  cases  the  longi- 
tudinal bands  on  the  colon  may  be  recognized,  or  even  the  sacculation 
of  the  large  intestine;  but  inflammatory  changes  or  distention  may 
obscure  such  means  of  identification.  The  large  intestine  in  fat  adults 
is  covered  by  epiploic  appendages;  but  in  children  and  emaciated 


826  ABDOMINAL  SURGERY   IN  GENERAL 

adults  these  are  absent.  The  safest  and  most  constant  distinction  is 
the  attachment  of  the  intestine  to  the  posterior  abdominal  wall  by 
its  mesenteries  (Da  Costa,  1894).  The  small  intestine  is  attached 
by  its  mesentery  obliquely  across  the  lumbar  spine:  the  coils  of  small 
bowel  rarely  can  be  brought  very  far  laterally  in  the  abdominal  cavity,  _ 
but  usually  occupy  its  middle  portion.  The  large  intestine  is  attached 
to  the  posterior  abdominal  wall  on  the  right  and  left  of  the  abdomen, 
and  transversely  above.  If  all  the  intra-abdominal  structures  are 
pushed  away  from  the  right  side  by  the  use  of  gauze  pads,  the  bowel 
which  it  will  be  impossible  to  push  away,  will  be  the  cecum  and  ascend- 
ing colon.  In  inserting  the  hand,  if  the  fingers  be  made  to  follow  the 
peritoneum  on  the  right  across  the  flank,  into  the  loin,  and  toward 
the  median  line,  the  first  bowel  they  encounter  attached  to  the  pos- 
terior abdominal  wall,  will  be  the  ascending  colon.  The  same  con- 
dition of  affairs  exists  on  the  left  side :  the  descending  colon  and  the 
sigmoid  have  their  posterior  attachments  further  to  the  left  than  any 
of  the  intestines,  and  after  all  the  movable  bowels  have  been  packed 
away  from  the  left  side,  the  immovable  intestine,  which  remains 
relatively  fixed,  will  be  the  descending  colon  or  sigmoid.  The  sigmoid 
often  has  a  long  mesentery,  and  the  sigmoid  loop  may  prolapse  into  a 
right  inguinal  incision.  The  same  is  true  of  the  transverse  colon, 
which  may  be  easily  accessible  from  either  iliac  region  or  the  hypo- 
chondrium.  But  the  transverse  co  on  is  easily  distinguished  from  other 
portions  of  the  large  bowel  because  it  has  the  great  omentum  attached 
to  it.  The  sigmoid  and  cecum  are  readily  distinguished  from  each 
other  by  their  mesenteric  insertions. 

The  mesentery  of  the  small  intestine,  as  already  noted,  crosses  the 
lumbar  spine  obliquely,  beginning  above  on  the  left,  and  ending  at 
the  cecal  region  on  the  right.  The  direction  in  which  a  coil  of  small 
bowel  is  running  {i.  e.,  which  end  is  nearer  the  duodeno-jejunal  junc- 
ture) can  be  ascertained  by  paying  attention  to  the  attachment  of  its 
mesentery.  The  coil  of  bowel  to  be  investigated  should  be  withdrawn 
from  the  abdomen,  spread  out,  and  untwisted,  until  the  fingers  can 
follow  the  mesentery  down  to  its  origin  or  root  along  the  lumbar 
spine.  If  the  bowel  is  not  rotated  on  its  mesentery,  it  is  evident  that 
it  is  running  in  the  same  direction  as  the  root  of  the  mesentery,  and 
hence  that  its  upper  (duodenal)  end  is  nearer  the  epigastrium  than  is 
its  lower  (cecal)  end.  The  upper  end  of  the  jejunum  is  readily  found 
by  lifting  the  great  omentum  and  with  it  the  transverse  colon  out  of 
the  abdomen,  and  turning  these  structures  upward  on  the  patient's 
thorax.  This  makes  the  transverse  mesocolon  taut,  and  the  jejunum 
is  seen  emerging  from  its  lower  layer  just  to  the  left  of  the  spinal 
column.  This  is  the  duodeno-jejunal  juncture.  The  duodenum  here 
is  retroperitoneal,  and  the  first  intraperitoneal  coil  of  gut  is  the  origin 
of  the  jejunum.  This  is  an  important  landmark  in  gastro-jejunostomy. 
The  lower  end  of  the  ileum,  or  the  ileo-cecal  juncture,  is  readily  found, 
by  running  the  fingers  upward  along  the  external  iliac  vessels  as  they 
lie   at  the   brim   of  the   true   pelvis.     The   structure   which  arrests 


INTESTIXA  L   L()(  'A  LIZA  'HON  827 

X\w  fiiif^tTs  in  till'  lu'if^hhorliood  of  the  ri^^lit  sacro-iliac  joint,  will  Ik-  the 
tiTniination  of  tlir  inesoiitery  of  the  ileum  where  this  passes  into 
the  (reuni.  With  a  little  praetiee  it  is  not  diffieult  to  scoop  up  into  the 
wound,  on  the  finger  tips,  the  ileo-eecal  loop,  and  thus  to  bring  the 


Fig.  813. — -The  mesenteric  arteries  in  the  upper  portion  of  the  jejunum.    There 
are  only  primary  vascular  loops,  and  the  vasa  recta  are  long. 

appendix  vermiformis  into  view\  Monks  (1903)  conducted  studies 
in  the  hope  of  being  able  to  diflferentiate  at  operation  betw^een  dif- 
ferent portions  of  the  jejuno-ileum,  without  the  necessity  of  tracing 
the  entire  small  intestine  dowmvard  from  its  origin  or  upward  from  its 
termination.     Chief  reliance  is  placed  on  the  arrangement  of  the 


Fig.  814. — The  mesenteric  arteries  in  the  middle  of  the  jejuno-ileum.     Secondarj' 
loops  are  well-developed,  and  the  vasa  recta  are  shorter. 

viesenieric  bloodvessels.  High  in  the  jejunum  there  are  only  primary 
vascular  loops,  with  perhaps  an  occasional  secondary  loop,  and  the 
vasa  recta  are  from  3  to  5  cm.  long  (Fig.  813).  Midw^ay,  sa}'  at  ten 
feet  from  either  end,  the  secondary  loops  are  a  prominent  feature  of 


828 


ABDOMINAL  SURGERY  IN  GENERAL 


the  mesenteric  vessels,  and  the  vasa  recta  are  shorter  (Fig.  814).  In 
the  lower  ileum  the  vessels  are  much  less  easily  distinguished,  owing 
to  the  deposition  of  fat  in  the  mesentery;  the  loops,  if  visible,  are 
much  more  complex,  and  the  vasa  recta  are  short  and  irregular  (Fig. 
815).  The  upper  jejunum  is  larger  in  diameter,  its  walls  are  thicker, 
and  often  the  valvulte  conniventes  are  palpable,  or  they  may  be  visible 
by  transmitted  light.  The  lower  ileum  is  smaller,  and  its  walls  are 
thinner. 


Fig.  815. — In  the  lower  ileum  the  mesenteric  bloodvessels  can  hardly  be  distinguished, 
owing  to  the  deposit  of  fat.  The  preparations  shown  in  Figs.  81.3,  814,  and  815  are  from 
the  laboratory  of  operative  surgery  in  the  University  of  Pennsylvania. 


Intestinal  Sutures. — The  underlying  principle  in  suture  of  organs 
covered  with  peritoneum  is  to  bring  serous  surfaces  into  contact. 
This  principle  appears  to  have  been  introduced  by  Jobert  de  Lamballe 
in  1824.  It  is  analogous  to  the  principle  adopted  in  surgery  of  the 
vascular  system  (Chapter  X),  always  to  bring  intima  into  contact 
with  intima.  Such  apposition,  both  of  the  intima  which  lines  blood- 
vessels and  of  the  peritoneum  which  covers  the  abdominal  viscera, 
results  in  much  more  rapid  and  certain  union  than  where  the  muscular 
or  fibrous  layers  of  these  structures  are  sutured  without  bringing  their 
serous  surfaces  into  contact. 

Any  suture  which  brings  serosa  into  contact  with  serosa  may  be 
called  a  sero-serous  suture.  There  are  many  varieties  of  this  suture 
in  use  at  the  present  day,  to  which  the  names  of  various  surgeons 
have  been  attached.  As  already  mentioned,  this  principle  was  used 
by  Jobert  in  1824;  but  in  1826  its  application  was  simplified  by  Lem- 
bert,  and  to  this  day  an  interrupted  sero-serous  suture  is  known  as  a 
Lembert  suture  (Fig.  816).  If  the  suture  did  not  hold  well  he  included 
tissues  down  to  the  mucous  coat  of  the  bowel,  and  Halsted,  in  1887, 
renewed  this  injunction.  It  is  said  that  it  is  easy  to  tell  by  the  sensa-  ' 
tion  imparted  to  the  surgeon's  hand,  when  the  needle  has  caught  up 
the  tough  submucous  tissue.  As  a  matter  of  fact  the  needle  often,  if 
not  indeed  usually,  penetrates  all  the  coats  of  the  intestine;  and  this 
makes  no  difference  so  long  as  no  fecal  leakage  occurs  along  the  needle 


IN TES TINA L  iSVT UREA'S 


.S29 


track.  This  is  prcxciiti'd  hy  tlic  use  of  (1)  rouiid-poiiitcd  lurdk's, 
and  (2)  linen  celluloid  thread  (I'agenstecher's  suture,  !!)()()),  wliich 
])()ssesses  no  capillarity.  This  suture  material  becomes  encapsulated 
and  remains  })ernianently. 

For  additional  security  in  intestinal  wounds,  and  especially  to  check 
bleeding;  from  the  cut  niaruins  of  the  bowel,  it  is  the  rule  to  enij)Ioy 
also  a  through-and-through  suture,  which  passes  through  all  the  coats 
of  the  intestine.     This  is  inserted  before  the  sero-serous  suture,  is 


Fig.  816. — Perforation  of  the  bowel,  Ijeinfj; 
clos(!d  hy  three  Lembert  sutures. 


Fig.  817. — a,  Czeruy-Lemljert  suture; 
b,  Albert-Lembert  suture.    (See  the  text.) 


knotted  within  the  lumen  of  the  bowel,  and  should  be  of  absorbable 
material  so  that  it  will  ulcerate  out  into  the  intestinal  canal  when 
union  is  firm.  Chromic  catgut  (No.  0  or  No.  1)  is  the  best  material. 
The  principle  of  the  through-and-through  suture  knotted  within  the 
lumen  of  the  bowel  we  owe  to  Albert.  A  diagram  of  the  Albert- 
Lembert  suture  is  shown  in  Fig.  817,  b.  Czerny's  suture  did  not 
penetrate  the  mucosa,  and  was  not  knotted  within  the  bowel  (Fig. 
817,  a). 


Fig.  818. — Gely's  suture. 


Fig,  819. — a,  The  first  points  of  a  Gely 
suture,  used  to  close  a  puncture,  b,  a 
purse-string  suture,  used  to  close  a  per- 
foration. 


Suture  of  Punctures  and  Perforations. — A  mere  puncture  may  be 
inverted  by  a  couple  of  Lembert  sutures  (Fig.  816)  or  by  the  first 
points  of  a  Gely  suture  (1844)  (Fig.  818).  A  perforation  usually  may 
be  closed  by  a  purse-string  suture  (Fig.  819,  6),  but  if  it  is  large  it 
must  be  sutured  as  a  wound  in  a  direction  either  transverse  or  parallel 


830 


ABDOMIXAL  SURGERY  IN  GENERAL 


to  the  long  axis  of  the  intestine,  whichever  puckers  the  bowel  less. 
As  there  seldom  is  bleeding  from  the  edges  of  a  perforation  it  is  not 
usually  necessary  to  use  a  through-and-through  suture,  the  sero-serous 
suture  being  sufficient. 

Suture  of  Incisions  or  Wounds. — Gunshot  wounds  resemble  perfora- 
tions and  require  the  same  treatment.  Ruptures,  lacerated  and 
incised  wounds,  especially  operation  wounds,  usually  require  first 
a  through-and-tlirough  suture  to  check  hemorrhage.     This  may  be 


Fig.  820. — Closure  of  an  intestinal 
wound  by  a  continuous  through-and- 
through  suture.  The  knots  lie  within 
the  lumen  of  the  gut. 


Fig.  821. — Continuous  sero-serous  suture 
(Dupuytren's  suture). 


either  interrupted  or  continuous.  The  needle  is  entered  at  one  end 
of  the  incision,  from  the  mucous  surface,  emerges  on  the  peritoneal 
surface,  crosses  to  the  opposite  side  of  the  incision,  and  there  again 
penetrates  all  the  coats  of  the  bowel  from  the  serous  to  the  mucous 
surface.  It  is  then  knotted;  the  knot  thus  lies  within  the  lumen  of  the 
bowel.  If  an  interrupted  suture  is  desired,  both  ends  of  the  thread 
are  cut  short,  and  other  sutures  introduced  about  one-half  a  centi- 
meter apart  until  the  wound  is  closed.  If  a  continuous  suture  is  pre- 
ferred, only  the  free  end  of  the  thread  is  cut  short,  and  the  needle  is 


Fig.  822. — Right-angled  sero-serous  suture  of  Cushing. 


re-introduced  on  one  side  of  the  wound  from  its  mucous  surface,  and 
traversing  all  the  coats  of  the  bowel,  emerges  on  the  peritoneal  sur- 
face. The  needle  is  then  carried  across  the  wound  to  its  opposite  lip; 
here  enters  the  serous  surface  of  the  bowel,  traverses  all  its  coats,  and 
emerges  on  the  mucous  surface.  This  completes  the  second  stitch, 
and  the  thread  is  then  drawn  taut,  carefully  inverting  the  lips  of  the 
wound  as  this  is  done.  Each  similar  stitch  is  pulled  taut  until  the 
other  end  of  the  wound  is  reached,  when  the  suture  is  knotted  and  the 


INTESTINAL  RESECTION 


831 


knot  is  allowed  to  retract  within  the  lumen  of  the  bowel  (Fig.  820). 
To  reinforce  this  throuiih-and-tiirouKh  suture,  a  coniinuous  scro-scrous 
suture  (known  also  as  i)upuytren's  suture)  is  applied  (Fig.  S21).  Any 
point  which  seems  weak  may  be  reinforced  again  by  an  interrupted 
suture.  When  there  is  much  tension  on  the  parts  a  sero-serous  suture, 
inserted  as  shown  in  Fig.  S22,  usually  holds  better;  it  is  known  as  the 
righi-auyird  srro-scwus  suture  (also  by  the  name  of  Ilayward  W. 
Gushing,  1889).  Or  a  mattress  suture,  either  interrupted  (Fig.  S23) 
or  continuous  (Fig.  S24)  may  be  employed;  this  is  known  })y  Ilalsted's 
name  (1887). 


Fig.  823. — Interrupted  mattress  suture. 
(Deaver  and  Ashhurst.) 


Fig.  824. — Continuous  mattress  suture- 
(Deaver  and  Ashhurst.) 


Intestinal  Resection.— When  it  is  necessary  to  resect  a  portion  of  the 
intestinal  canal,  the  mesentery  is  first  tied  off.  This  is  done  by  a 
series  of  interlocking  ligatures  applied  about  an  inch  from  the  intes- 
tinal attachment  of  the  mesentery,  and  never  over  quite  as  wide  an 
area  as  the  length  of  gut  to  be  removed,  for  fear  of  endangering  its 
vitality.  The  gut  above  and  below  the  diseased  area  is  then  double 
clamped:  suitable  clamps,  with  their  blades  covered  by  rubber  tubing, 
introduced  into  surgery  by  Rydygier  (1881),  and  popularized  by 
Doyen  (1900),  may  be  applied  to  healthy  bowel,  and  if  clamped  only 
tight  enough  to  appose  the  mucous  surfaces  may  remain  in  place  for 
an  hour  or  more  without  inflicting  any  injury.  These  clamps  should 
have  light,  elastic  blades,  which  meet  at  their  tips  before  the  bodies 
of  the  blades  come  together  (Fig.  825).  They  prevent  fecal  extrava- 
sation and  also  serve  the  purpose  of  temporary  hemostasis,  like  the 
elastic  band  of  Esmarch  used  in  amputating.  In  emergency  pieces  of 
tape  may  be  tied  around  the  bowel. 

Such  clamps  should  be  applied  to  the  healthy  bowel  an  inch  or  more 
above  and  below  the  proposed  limits  of  resection.  Any  ordinary  clamp 
forceps  are  then  applied  at  the  limits  of  the  diseased  area,  w^hich  is  thus 
cut  at  each  end  between  two  pairs  of  clamps  (Fig.  826),  so  that  no 
fecal  extravasation  occurs. 

The  subsequent  procedure  depends  upon  whether  it  is  desired  to 
restore  the  continuity  of  the  intestinal  canal  by  anastomosis,  or  to 
establish  [a  false  anus  in  the  wound.  The  best  way  to  establish  a 
false  anus  after  intestinal  resection  is  to  suture  the  two  coils  of  bowel 
together  like  a  double-barrelled  shotgun—"  en  canon  de  jusil,"  as  the 


832 


ABDOMINAL  SURGERY  IX  GEXERAL 


French  call  it.  This  is  easily  accomplished  by  a  few  sero-serous 
sutures.  Then  the  circumference  of  each  intestinal  coil  is  sutured 
to  the  parietal  peritoneum,  leaving  about  an  inch  of  each  gut  pro- 
truding from  the  wound.    The  clamps  used  for  resection  may  be  left 


Fig.  82.5. 


-Clamps  used  in  gastric  and  intestinal  surgery.    Note  the  form  of  the  blades; 
in  the  upper  (three-bladed)  forceps  the  rubber  tubing  is  in  place. 


on  the  protruding  ends  for  a  few  days  (or  until  the  peritoneal  cavity 
is  shut  off  by  adhesions),  if  there  is  no  urgent  need  to  secure  a  fecal 
evacuation;  or  the  ends  may  be  simply  ligated  and  be  left  to  open 
themselves  when  the  slough  separates.    Other  methods  of  forming  a 


Fig.  826. — Intestinal  resection.    After  the  mesentery  has  been  ligated  and  cut  close  to 
the  bowel,  the  resection  clamps  are  appUed,  and  the  diseased  bowel  is  cut  away. 

false  anus  are  discussed  at  p.  914;  and  the  treatment  of  this  condition 
is  considered  at  p.  894. 

Intestinal  Anastomosis. — This  may  be  accomplished  by  uniting  the 
gut  end-to-end  (circular  enterorrhaphyj ;  or,  after  closing  the  open  ends 


INTESriNA L   ANASTOMOSIS 


833 


of  tlic  intestines,  tliese  may  he  plaeed  side  by  .side  and  a  lateral  anas- 
tomosis may  be  establislicd  (X.  Senn,  1889).  By  an  implantation  is 
understood  an  operation  in  which  the  end  of  one  bowel  is  sutured  into 
the  side  of  another,  mnoli  as  the  ileum  is  implanted  into  the  cecum. 
End-to-end  Anastomosis.— The  rubber-covered  clamps  employed 
durinsj;  he  intestinal  resection  are  left  in  place.  By  bringing?  them 
parallel  to  each  other,  the  ends  of  the  gut  are  approximated;  these 
then  look  at  the  surgeon  like  a  double-})arrelled  shot-gun.  This  brings 
four  layers  of  intestinal  wall  to  view,  two  of  which  are  apposed. 


Fig.     827. — Encl-to-ond    aimstoinosis.     The 
through-and-through  suture  has  been  started. 


Fig.  828. — End-to-end  anastomo- 
sis. Passing  the  through-and-through 
suture  at  the  mesenteric  attachment. 


1.  First,  a  continuous  through-and-through  suture  of  cliromic 
catgut  is  applied:  this  is  begun  by  introducing  the  needle  from  the 
mucous  surface  of  that  coil  of  gut  on  the  operator's  right,  at  the  anti- 
mesenteric  point.  The  needle  is  pushed  through  the  apposed  intes- 
tinal walls  from  the  lumen  of  one  gut  into  that  of  the  other,  where  it 
emerges  on  the  mucous  surface,  having  in  its  course  traversed  all 
intervening  layers  of  both  guts:  of  the  first  coil  from  the  mucous  to  the 
serous,  and  of  the  second  coil  from  the  serous  to  the  mucous  surface. 
The  first  stitch  is  then  tied,  the  knot  coming  within  the  lumen  of  the 
bowel.  The  end  is  left  long.  The  suturing  is  then  continued  (Fig. 
827)  toward  the  mesenteric  attachment,  and  when  this  is  reached  the 
suture  is  passed  as  indicated  in  Fig.  828.  The  suture  is  continued  around 
the  margin  of  the  gut,  always  passing  from  the  mucous  to  the  serous 
surface  of  the  first  coil  and  from  the  serous  to  the  mucous  siu-face  of 
the  second  coil  of  bow^l.  When  the  point  of  beginning  is  reached  at 
last,  the  suture  is  terminated  by  knotting  it  to  the  original  end,  which 
was  left  long  for  this  purpose.  When  both  ends  are  cut  short,  the  knot 
disappears  into  the  lumen  of  the  bowel. 

2.  The  clamps  may  then  be  removed,  and  the  operation  is  com- 
pleted by  passing  a  continuous  sero-serous  suture  around  the  entire 
anastomosis,  thus  reinforcing  the  through-and-through  suture. 

3.  The  mesentery  will  become  redundant  when  the  intestinal  ends 
are  approximated;  its  free  border  may  be  stitched  to  the  anastomosis. 

53 


834 


ABDOMINAL  SURGERY  IN  GENERAL 


]\Iaunsell  (1892)  thought  it  facihtated  the  operation  of  circular 
enterorrhaphy  to  evaginate  the  divided  ends  through  a  longitudinal 
incision  in  one  of  the  coils  of  intestine.  After  suture  of  the  divided  ends 
has  been  thus  completed,  from  their  mucous  surface,  they  are  replaced, 
and  the  intestinal  incision  through  which  they  were  withdrawn  is 
closed.  A  partial  intussusception  of  the  sutured  ends  remains  (Fig. 
829). 

M.  E.  Connell  (1892)  advocated  only  interrupted  mattress  sutures, 
penetrating  all  the  coats  of  the  bowel,  and  tied  on  their  mucous 
surface. 


Fig.  829. — Maunsell's  method  of  circular  enterorrhaphy.  a,  the  incision  in  one  coil 
of  intestine;  b,  the  open  ends  of  both  coils  evaginated  through  this  incision,  to  facilitate 
suturing;  c,  the  operation  completed. 


t/  Lateral  Anastomosis. — The  open  ends  of  the  resected  bowel  must 
first  be  closed.  If  the  limien  of  the  gut  is  small,  it  is  sufficient  to  apply 
a  ligature  in  the  groove  made  by  a  crushing  clamp,  as  in  the  operation 
of  appendicectomy  (p.  856)  and  to  invert  this  ligature  by  a  purse- 
string  sero-serous  suture.  When  the  guts  are  to  be  left  in  or  near 
the  wound  after  the  lateral  anastomosis  has  been  completed  (as  in 
some  cases  of  resection  for  strangulated  hernia),  it  is  sufficient  to  apply 
a  strong  ligature,  as  above  described,  without  a  secondary  inverting 
purse-string  suture.  Thus  time  is  saved.  In  most  instances,  however, 
and  especially  where  the  lumen  of  the  resected  gut  is  of  large  size, 
it  is  safer  to  close  the  end  of  the  bowel  by  two  layers  of  sutures,  the 
first  being  a  continuous  tlirough-and-through  suture  of  chromic  catgut, 
and  the  second  a  linen  sero-serous  suture. 

Lateral  anastomosis  should  be  made  in  an  iso-peristaltic  direction 
(Fig.  830);  though  where  afferent  and  efferent  loops  are  sutured 
together  en  canon  de  fusil,  and  an  anastomosis  is  subsequently  estab- 
lished, the  antiperistaltic  direction  of  the  anastomosis  appears  to  make 
little  difference  (Fig.  831). 


IN TKSTINA  L  A  NA STOMOSIS 


^^r^ 


The  formation  of  n  lateral  anastomosis  is  nnicli  facilitated  bv  the 
use  ot  rnl.hcr-covcro.l  intestinal  clamps.  The  three-bluded  "Roosevelt 
elamp,    or  one  ol  snnilar  pattern,  is  very  convenient  (Fig.  825)     The 


) 


_j 


Fig.  !S30. — Lateral   anastomosis   with 
intestinal  coils  in  iso-peristaltic  relation. 


Fig.  831. — Lateral  anastomosis 
with  intestinal  coils  in  anti-peris- 
taltic r(>hiti()n. 


830  ABDOMINAL  SURGERY  IN  GENERAL 

clanij)  should  be  applied  so  as  to  embrace  a  considerably  greater  area 
of  bowel  than  that  concerned  in  the  anastomosis.  The  anastomosis 
is  made  on  the  free  (antimesenteric)  border  of  the  intestinal  loops. 

1.  The  first  step  consists  in  the  insertion  of  a  continuous  linen  sero- 
serous  suture  close  to  the  median  blade  of  the  clamp,  for  a  distance 
a  little  longer  than  the  size  of  the  proposed  intestinal  opening,  say 
about  8  to  10  cm.  This  suture  is  begun  at  one  end  of  the  proposed 
intestinal  opening,  where  it  is  knotted,  the  free  end  being  left  long; 
it  is  continued  in  a  straight  line  to  the  other  end  of  the  proposed  anas- 
tomosis, uniting  the  two  coils  of  intestine,  as  indicated  in  Fig.  S.32. 
When  this  point  is  reached  the  suture  is  not  cut,  but  the  needle,  still 
threaded,  is  laid  aside  temporarily,  to  be  used  again  before  the  close 
of  the  operation.  This  needle  and  thread  will  be  referred  to  as  the 
sero-serous  suture. 

2.  The  surgeon  then  makes  a  longitudinal  incision  in  one  of  the 
coils  of  bowel,  about  one  centimeter  distant  from  and  parallel  to  the 
sero-serous  suture  already  applied,  and  about  6  to  8  cm.  in  length. 
This  incision  divides  first  the  serous  and  muscular  coats  of  the  gut; 
as  these  retract  the  mucosa  pouts  into  the  incision.  The  mucosa  is 
cautiously  opened  at  one  point,  so  as  not  to  wound  the  opposite  wall 
of  the  bowel.  Any  discharge  from  the  lumen  of  the  bowel  is  wiped 
carefully  away.  Then  the  opening  in  the  mucosa  is  enlarged  by 
scissors  to  the  full  extent  of  the  intestinal  incision.  If  the  mucosa 
seems  redundant,  as  is  often  the  case  in  the  small  intestine,  it  should 
be  excised.  The  other  coil  of  gut  is  then  opened  in  a  similar  way  for 
an  equal  distance.  There  are  now  exposed  in  the  wound  two  apposed 
loops  of  intestine,  each  with  a  longitudinal  incision  in  its  antimes- 
enteric border.  Each  of  these  incisions  has  two  lips,  an  anterior  and 
a  posterior.  The  two  posterior  lips  are  fairly  close  together,  while 
the  anterior  lips  are  some  distance  apart.  For  purposes  of  descrip- 
tion it  is  convenient  to  apply  definite  names  to  these  structures:  we 
may  speak  of  the  coil  of  bow^el  on  the  operator's  right  as  the  first  gut, 
and  that  on  his  left  as  the  second  gut  (frequently  it  is  impossible  to 
know  which  of  these  is  the  afferent  and  which  is  the  efferent  loop); 
each  of  these  guts  has  an  incision  with  an  anterior  and  a  posterior  lip; 
the  posterior  lips  are  closely  apposed  to  each  other.  Where  the 
anterior  and  posterior  lip  of  each  incision  join,  is  found  the  angle  of 
the  incision;  one  angle  is  at  the  end  of  the  intestinal  incision  away 
from  the  operator  {the  far  angle  of  the  incision)  and  the  other  is  at  the 
near  end  of  the  incision  (the  near  angle  of  the  incision) . 

3.  A  through-and-through  continuous  suture  of  chromic  catgut  is 
now  to  be  inserted.  The  needle  is  entered  at  the  near  angle  of  the 
incision  in  the  first  gut,  from  its  mucous  surface,  and  traverses  all  its 
coats,  emerging  on  its  serous  surface;  it  s  then  inserted  at  the  near 
angle  of  the  second  gut,  passing  from  its  serous  to  its  mucous  surface. 
This  stitch  is  then  tied,  the  knot  coming  within  the  lumen  of  the  bowel. 
The  end  of  the  suture  is  left  long;  it  should  not  be  confused  with  the 
end  of  the  sero-serous  suture  (linen),  which  also  was  left  long.    The 


INTESTINA L  A NASTO.VOSIS 


837 


throuf^h-and-throufili  chrDinic  f-atj^ut  suture  is  continued  away  from 
the  operator,  uniting  tiie  posterior  lips  of  the  intestinal  ineisions, 
as  shown  in  Fig.  So3,  until  the  far  angk-s  of  the  incisions  are  reached. 
During  this  time  the  needle  ;s  passed  always  from  tlie  nuieous  surface 
of  the  first  gut  through  all  its  coats  to  its  serous  surface,  and  imme- 
diately into  the  serous  surface  of  the  second  gut,  emerging  on  the 
mucous  surface  of  the  second  gut.  Then  the  thread  is  drawn  taut; 
the  needle  is  carried  hack  to  the  side  from  which  it  started,  and  again 
enters  the  mucous  surface  of  the  first  gut,  traverses  all  its  coats  to 
emerge  on  its  serous  surface,  and  at  once  enters  the  serous  surface  of 
the  second  gut,  and,  traversing  all 
its  coats,  emerges  on  its  mucous 
surface  in  the  lumen  of  the  second 
gut.  This  is  accomplished  each  time 
by  one  push  of  the  needle,  which  is 
enabled  to  pass  through  the  walls 
of  both  guts  "all  at  one  bite,"  be- 
cause the  posterior  lips  of  the  intes- 
tinal incisions  are  so  closely  approxi- 
mated. When,  however,  the  far 
angles  of  the  intestinal  openings  are 
reached,  it  is  no  longer  possible  for 
the  needle  to  pass  through  the  walls 
of  both  guts  all  at  one  bite,  but 
it  is  necessary  for  it  to  be  passed 
tlirough  each  separately.  But  the 
same  method  of  suturing  may  be 
continued:  thus  the  needle  always 
enters  the  first  gut  from  its  mucous 
surface  and  emerges  on  its  serous 
surface;  it  then  is  carried  across 
to  the  free  margin  of  the  second 
gut  (at  its  far  angle  or  on  its  an- 
terior lip),  and  always  enters  its 
wall  from  the  serous  surface  and 
emerges  on  its  mucous  surface. 
This  is  readily  understood  by  refer- 
ence to  Fig.  833.  This  method  of  suturing  is  continued  along  the 
anterior  lips  of  the  intestinal  incisions  toward  the  operator  until 
the  near  angles  of  the  incisions  are  reached,  when  a  complete  cir- 
cumference will  have  been  traversed  by  the  through-and-through 
cliromic  catgut  suture,  which  is  finally  knotted  to  its  original  end, 
which  was  left  long  for  this  purpose  at  the  starting-point,  the  near 
angles  of  the  intestinal  incisions.  As  this  suture  is  being  inserted  in 
the  anterior  lips  these  should  be  carefully  inverted  so  as  to  ensure 
accurate  contact  of  their  serous  surfaces.  If  there  is  difficulty  in 
securing  proper  inversion  of  the  anterior  lips,  it  is  a  very  good  plan 
to  use  for  this  part  of  the  operation  a  continuous  right-angled  suture 


Fig.  833.  —  Lateral  anastomosis:  the 
through-and-through  suture  has  united 
the  posterior  lips  of  the  intestinal  inci- 
sions, and  the  far  end  of  these  incisions 
has  been  reached. 


838 


ABDOMINAL  SURGERY  IN  GENERAL 


similar  to  the  sero-serous  suture  of  Gushing  (Fig.  822),  except  that 
here  the  right-angled  suture  should  penetrate  all  the  coats  of  the 
intestine,  leaving  the  loop  of  the  suture  always  on  the  mucous  surface 
of  the  bowel  (Fig.  834).  This  is  known  as  C.  II.  Mayo's  suture  (1905). 
It  is  nothing  else  than  a  right-angled  through-and-through  suture. 

4.  When  the  application  of  the  through-and-through  suture  has  been 
completed,  the  rubber  clamps  may  be  released,  but  should  not  be 
removed  from  their  position,  as  they  serve  to  keep  the  parts  accessible 
for  the  application  of  the  final  suture.  This  is  a  continuation  of  the 
sero-serous  suture  first  applied,  the  needle  of  which,  still  threaded, 

was  laid  aside  temporarily  be- 
fore the  application  of  the 
through-and-through  suture 
was  commenced.  This  sero- 
serous  suture  is  now  continued 
over  the  inverted  anterior  lips 
of  the  intestinal  anastomosis, 
further  inverting  them  and 
burying  from  sight  the  through- 
and-through  suture.  The  sero- 
serous  suture  is  finally  arrested 
at  the  near  angle  of  the  anas- 
tomosis, where  it  is  knotted  to 
its  own  original  free  end,  which 
was  left  long  for  this  purpose. 
The  clamps  are  then  entirely 
removed ;  the  anastomosis  is  in- 
spected on  all  sides,  any  weak 
spot  being  reinforced  by  one  or 
two  additional  interrupted  sero- 
serous  sutures.  The  intestines 
are  then  replaced  within  the 
abdomen. 

The  advantages  of  lateral  over 
end-to-end  anastomosis  are  the 
following:  the  opening  may  be 
made  of  any  desired  size;  there 
is  no  mesenteric  attachment  to  be  included  in  the  sutures,  and  no  fear  of 
leakage  at  this  weak  point.  The  chief  disadvantage  is  the  additional 
time  required  for  its  performance,  when  it  is  employed  after  intestinal 
resection,  because  then  it  involves  also  closure  of  two  ends  of  bowel. 
After  lateral  anastomosis  following  intestinal  resection  the  coils  of 
bow^l  involved  tend  to  straighten  out,  so  that  after  some  years  little 
or  no  trace  of  the  anastomosis  can  be  found,  even  when  it  was  made 
in  an  antiperistaltic  direction.  Lateral  anastomosis  I  believe  should 
be  preferred  (1)  whenever  the  large  bowel  is  concerned,  as  this  has  a 
relatively  large  extraperitoneal  surface  and,  therefore,  usually  is  not 
well  adapted  for  an  end-to-end  anastomosis;  (2)  in  cases  where  the 


Fig.  834.  —  Lateral  anastomosis:  the  far 
angles  of  the  Intestinal  incisions  have  been 
sutured,  and  the  anterior  lips  of  the  incisions 
are  now  being  united  by  the  through-and- 
through  suture  which  is  passed  in  a  manner 
similar  to  the  sero-serous  suture  shown  in 
Fig.  822. 


INTESTINA L  A NASTO.\f()SIS 


S39 


two  coils  of  <jut  to  be  anastoiiiosed  dill'cT  inuch  in  diainctcr,  thoiiji:li  hy 
careful  suture  or  by  cutting  the  smaller  intestinal  loop  ol)li(juely  it  is 
possible  to  employ  end-to-end  anastomosis  even  under  such  circum- 
stances; and  (3)  in  cases  where  the  intestinal  walls  arc  altered  from 
inflannnatory  changes,  as  in  most  cases  of  acute  intestinal  obstruction, 
strangulated  hernia,  etc.  Knd-to-end  anastomosis  I  think  is  best 
limited  to  resections  of  small  intestine  not  undertaken  in  the  presence 
of  acute  disease. 


I'lG.  835. — The  Murphy  button  for  intes- 
tinal anastomosis;  above,  the  female  half; 
below,  the  male  half  of  the  button. 


Fig.  836. — Two  coils  of  intestine 
anastomosed  by  means  of  the  Murphy 
button. 


Mechanical  devices  for  intestinal  anastomosis  are  not  much  used  by 
surgeons  any  more.  The  Murphy  button,  introduced  by  J.  B.  Murphy, 
in  1892,  is  still  the  most  popular  in  this  country,  as  is  the  somewhat 
similar  contrivance  of  Jaboulay,  in  France,  and  Mayo  Robson's  bone 
bobbin,  in  England.  The  Murphy  button  is  a  very  ingenious  contriv- 
ance, made  of  metal,  nickel-plated;  it  consists  of  two  parts  (Fig.  835), 
one  of  which  is  inserted  through  a  small  incision  into  each  of  the  loops 
of  bowel  to  be  anastomosed,  and  is  held  in  place  by  a  purse-string 
suture  which  puckers  the  bowel  around  the  half  of  the  button  inserted. 
The  projecting  shanks  of  each  end  of  the  button  are  then  forced 
together,  the  male  within  the  female;  the  two  halves  of  the  button  are 
thus  held  together  automatically  by  a  spring.  Serous  surfaces  are  thus 
brought  into  broad  apposition  (Fig.  836).  The  union  may  be  reinforced 
by  a  few  interrupted  sero-serous  sutures.  The  button  is  provided  with 
a  lumen  in  its  centre,  and  if  all  goes  well  it  ulcerates  into  the  lumen 
of  the  intestine  in  ten  days  or  two  weeks  and  is  passed  by  rectum. 
During  the  application  of  the  button  its  lumen  may  be  filled  with 
cocoa  butter,  which  will  prevent  fecal  extravasation  temporarily,  but 
melts  as  soon  as  the  intestines  are  returned  to  the  abdomen.  I  have 
never  used  any  mechanical  device  in  effecting  intestinal  anastomosis, 
but  believe  the  jNIurphy  button  better  than  any  other  such  appliance. 
It  is  particularly  indicated  where  the  parts  concerned  in  the  operation 


840  ABDOMINAL  SURGERY  IN  GENERAL 

cannot  be  brought  into  the  wound  so  as  to  render  accurate  suture 
possible,  or  where  very  rapid  conclusion  of  the  operation  becomes 
imperative.  The  chief  danger  from  the  use  of  the  button  is  that  its 
mechanism  may  be  defective,  so  that  it  may  ulcerate  out  too  soon, 
allowing  fecal  extravasation  and  causing  death  from  peritonitis.  It 
should  be  an  invariable  rule  for  the  surgeon  himself  personally  to  test 
the  mechanism  of  the  button  thoroughly  and  several  times  before 
the  operation  is  commenced.  Occasionally  the  button  has  caused 
intestinal  obstruction. 

INJURIES  OF  THE  ABDOMEN. 

Subcutaneous  Injuries. — These  may  affect  the  abdominal  wall 
only,  or  there  may  be  visceral  injury  with  or  without  injury  of  the 
overlying  structures.  In  almost  all  cases  the  injury  is  by  direct  vio- 
lence, blunt  force  in  the  form  of  a  blow,  a  kick,  a  fall,  or  a  crush,  being 
applied  to  the  abdominal  wall.  If  the  abdominal  muscles  are  rigidly 
contracted,  the  blow  a  glancing  one,  the  force  not  very  great,  and  the 
viscera  not  distended  or  weakened  by  disease,  only  a  contusion  of  the 
abdominal  wall  may  result.  If  the  force  is  greater,  rupture  of  the 
abdominal  wall  may  occur;  this  was  referred  to  at  p.  273.  Rupture 
of  one  of  the  abdominal  muscles  from  voluntary  contraction  sometimes 
occurs  in  cases  of  typhoid  fever;  I  have  seen  one  case,  apparently  of 
this  nature,  complicating  pneumonia. 

When  there  is  visceral  injury  it  usually  is  because  the  abdominal 
muscles  have  been  taken  off  their  guard,  or  because  they  are  very 
flabby  and  weak.  Then  the  force  need  not  be  very  great,  especially 
if  the  hollow  viscera  are  distended  or  the  solid  viscera  enlarged  by 
disease.  In  these  cases  no  macroscopic  evidence  of  injury  to  the 
abdominal  wall  may  be  found.  Visceral  injury  without  injury  of  the 
abdominal  wall  is  much  more  frequent  than  rupture  of  the  abdominal 
wall  without  visceral  injury.  The  gravity  of  the  injury,  as  pointed 
out  at  p.  181,  depends  largely  upon  the  momentum  of  the  vulnerating 
body :  a  mere  tap  on  the  abdomen  from  a  heavy  swinging  crane,  or 
block  and  tackle,  will  do  much  more  damage  than  a  smart  blow  with 
a  stick.  Sometimes  a  fall  inflicts  injury  by  indirect  violence,  one  of 
the  abdominal  viscera  being  torn  from  its  moorings  by  the  jar  when 
the  patient  lands  on  his  buttocks  or  feet;  but  this  is  very  rare. 

Most  cases  of  abdominal  injury  occur  in  men  during  active  adult 
life,  or  in  children.  An  irreducible  hernia  is  an  important  predisposing 
factor:  not  so  much  that  the  structures  in  the  hernial  sac  are  injured, 
but  because  the  intra-abdominal  organs  are  held  taut,  and  thus  are 
unable  to  escape  from  a  crushing  force.  This  was  the  case  in  two  out 
of  five  patients  upon  whom  I  have  operated  for  subcutaneous  rupture 
of  the  abdominal  viscera. 

The  intestinal  trad  is  most  often  injured.  Its  more  fixed  portions 
(duodeno-jejunal  juncture,  lower  ileum  and  cecum)  are  most  exposed 
to  injury.    The  injury  may  be  a  mere  contusion,  which  may  or  may 


INJURIES  OF   Till':  MiDOMEN  S41 

not  terminate  in  <];anp;ron('  and  perforation;  rn])tnre  may  occnr;  or  the 
howel  may  he  torn  loose  from  its  nu'sentery.  l{nj)tnres  nsually  oecur 
on  the  anti-mesenteric  horder  of  the  gut,  and  seem  to  be  caused  by 
over-(Hstention  of  the  intestine  with  a  resulting  explosive  injury,  a 
coil  of  gut  being  compressed  so  as  to  dam  up  its  contents  against  an 
obstruction,  such  as  the  ileo-cecal  valve  or  a  kink  between  adjacent 
intestinal  loops.  A  few  cases  of  rupture  of  the  large  bowel  ha\e  been 
reported  from  the  injection  of  compressed  air  into  the  rectum.  Rup- 
tures of  the  stomach  have  occurred  from  too  forcible  lavage,  and  from 
artificial  distention  with  Seidlitz  powders;  this  is  especially  to  })e  feared 
in  cases  of  gastric  carcinoma,  and  in  unconscious  patients.  Sponta- 
neous rupture  of  the  stomach  has  been  reported  as  a  result  of  vom- 
iting, fermentative  distention,  etc.  Complete  transverse  ruptures 
occur  oftenest  at  the  duodeno-jejunal  juncture.  Crushes  of  the  intes- 
tine result  from  pressure  between  the  body  which  inflicts  the  injury 
and  the  sacral  promontory  or  lumbar  spine.  In  this  way  the  lower 
ileum  is  often  torn  loose  from  its  mesentery. 

The  solid  organs  are  less  often  the  seat  of  injury  than  is  the  gastro- 
intestinal tract.  The  spleen  and  liver  are  much  more  frequently 
injured  than  is  the  pancreas,  which  is  in  a  protected  situation.  The 
liver  or  spleen  may  be  penetrated  by  the  fragments  of  broken  ribs, 
but  usually  the  lesion  is  a  rupture  from  diflfuse  compression.  The 
rupture  may  be  entirely  subcapsular,  or  may  extend  to  the  surface 
of  the  organ. 

Symptoms  and  Diagnosis. — Often  there  is  considerable  shock; 
usually  there  is  vomiting;  local  pain  causes  shallow  and  thoracic 
respiration.  Pain  is  the  most  constant  symptom,  and  where  fecal 
extravasation  occurs  it  may  be  agonizing.  The  abdominal  wall  is 
very  rigid,  and  physical  examination  is  unsatisfactory. 

If  there  is  only  a  severe  contusion  of  the  abdominal  wall,  without  vis- 
ceral injury,  the  general  condition  of  the  patient  is  not  much  afi'ected, 
even  at  first,  and  it  rapidly  improves.  The  pain  is  not  very  great, 
but  tenderness  and  rigidity  usually  are  very  pronounced.  It  is  very 
difficult  to  exclude  visceral  injury  certainly,  and  in  most  cases  explora- 
tory laparotomy  is  indicated.  If  there  is  a  large  niphire  of  the  gastro- 
intestinal tract,  permitting  fecal  extravasation,  the  pain  is  extremely 
severe;  but  if  the  rupture  is  very  small  it  may  be  occluded  by  the 
mucosa,^  and  there  may  be  comparatively  little  pain.  Serious  symp- 
toms follow  intra-abdominal  hemorrhage  even  when  there  is  no  injury 
of  the  gastro-intestinal  tube.  A  significant  symptom  in  cases  with 
visceral  injury  is  a  steady  increase  in  the  pulserate;  usually  the 
temperature  also  rises,  and  leukocytosis  develops.  Later  the  signs 
of  peritonitis  develop.  If  there  is  a  rupture  of  one  of  the  solid  organs, 
or  of  the  omentum  or  mesentery,  signs  of  internal  hemorrhage  usually 
precede  the  onset  of  peritonitis.  Emphysema  of  the  abdominal  wall 
(a  valuable  but  very  rare  sign),  indicates  rupture  of  a  hollow  viscus. 

1  In  all  injuries  sustained  during  life  the  mucosa  is  everted  into  the  rupture; 
this  is  not  the  case  if  the  rupture  takes  place  after  death  (Whitney). 


842  ABDOMINAL  SURGERY  IN  GENERAL 

The  only  certain  way  to  exclude  visceral  injury  is  by  exploratory 
laparotomy,  and  usually  this  is  postponed  too  long. 

Ruptures  of  the  gastro-intestinal  tract  almost  always  are  due  to  injury 
from  the  front.  Apart  from  the  very  severe  pain,  mentioned  above, 
the  occurrence  of  repeated  vomiting,  of  widespread  tenderness  and 
rigidity,  or  of  blood  in  the  stools,  indicates  injury  of  a  hollow  viscus. 

Rupture  of  the  liver  is  due  to  injury  to  the  right  hypochondriac 
region  or  lower  thorax.  As  noted  above,  fracture  of  the  ribs  may  be 
present,  with  puncture  of  the  liver  by  a  fragment.  The  rupture  usually 
is  in  the  right  lobe,  involves  the  capsule  of  Glisson,  and  permits  intra- 
peritoneal hemorrhage.  The  chief  symptoms  are  those  of  internal 
hemorrhage.  Jaundice  may  develop  after  several  days.  Rupture  of 
the  gall-bladder  or  hile-ducts  allows  extravasation  of  bile,  and  peri- 
tonitis develops  early  or  late  according  to  the  infectiousness  of  the 
bile. 

Rupture  of  the  spleen  is  most  frequent  in  cases  of  malarial  hyper- 
trophy, and  under  such  circumstances  may  occur  from  very  slight 
trauma,  or  even  spontaneously.  Other  enlargements  of  the  spleen 
also  predispose  it  to  rupture.  This  occurrence  during  typhoid  fever 
is  rare,  and  usually  fatal.  Rupture  of  the  normal  spleen  usually  is  due 
to  severe  injury  directly  over  the  left  hypochondriac  region,  lower 
thorax  or  loin;  but  if  the  spleen  is  enlarged  it  may  be  ruptured  or  torn 
loose  from  its  supports  by  indirect  violence. 

Rupture  of  the  Kidney. — See  p.  984. 

Rupture  of  the  Rladder. — See  p.  971. 

Treatment. — If  there  is  reasonable  doubt  as  to  the  presence  of 
visceral  injury,  the  patient  should  be  carefully  studied  for  three  or 
four  hours  after  the  accident.  If  there  is  only  contusion  of  the  abdomi- 
nal wall,  distinct  improvement  usually  occurs  within  this  time.  If  no 
improvement  occurs,  I  believe  exploration  is  imperative,  even  if  the 
patient  does  not  seem  to  be  growing  worse.  The  mortality  without 
operation  is  96  per  cent.  The  earlier  the  operation  the  more  chance 
there  is  of  its  being  successful;  isolated  case  reports  show  that  the 
death  rate  after  operation  within  twenty  four  hours  of  injury  is  about 
55  per  cent.  The  general  mortality  after  operation,  in  consecutive 
series  of  cases,  is  about  85  per  cent.  (Meerwein,  1907).  Until  operation 
is  done,  the  shock  should  be  treated;  and,  after  matcing  a  diagnosis, 
morphin  may  be  administered  to  allay  pain.  In  cases  of  mere  con- 
tusion an  ice  bag  or  hot  water  bag  locally  may  be  soothing.  After 
operation,  treatment  as  for  peritonitis  is  indicated-  (p.  810). 

Operation. — Unless  there  are  definite  indications  of  the  seat  of  the 
lesion,  a  left  paramedian  incision  should  be  made  just  below  the 
umbilicus.  Do  not  let  the  intestines  escape  from  the  wound.  If 
there  is  free  air  in  the  peritoneal  cavity,  or  if  gastric  or  intestinal 
contents  are  found,  it  is  clear  that  the  gastro-intestinal  tract  is 
ruptured.  If  the  abdomen  is  full  of  blood,  it  probably  comes  from  a 
solid  organ  or  from  the  omentum  or  mesenteries.  If  the  operation 
has  been  delayed,  the  presence  of  recent  adhesions,  lymph,  etc.,  will 


INJURIES  OF   Till':  ABDOMEN  843 

serve  as  a  guide  to  the  seat  of  rupture.  If  these  are  abseut,  tlie  iutes- 
tine  must  he  examined  in  detail,  hej-iuuiug  at  the  ileo-eeeal  juncture, 
and  passing  upward  toward  the  duodenum.  Not  more  than  two  or 
tiiree  feet  of  small  intestine  sliould  he  outside  the  abdomen  at  any 
one  time.  Most  ruptures  are  in  the  lower  ileum.  If  active  hemor- 
rhage is  found,  this  should  be  checked  before  anything  else  is  done. 
For  this  purpose  it  is  best  to  pack  all  the  intestines  away  first  to  one 
side  of  the  wound  and  then  to  the  other  and  examine  all  structures 
in  turn  on  the  right  and  on  the  left,  from  the  spinal  gutter  forward 
and  from  diai)hragm  to  pelvis.  Eventration  of  the  intestinal  tube 
does  not  facilitate  the  search;  it  is  best  to  keep  the  intestines  inside 
the  abdomen  as  much  as  possible.  Do  not  hesitate  to  make  your 
incision  large  enough  to  facilitate  rapid  operating. 

Intestinal  Traci.—\  rupture  of  the  antimesenteric  border  usually 
can  be  repaired  by  suture,  as  described  for  perforations  (p.  829); 
resection  of  the  intestine  should  be  avoided  if  possible.  A  complete 
transverse  rupture  should  be  treated  by  lateral  anastomosis,  or,  as 
a  last  resort,  and  only  when  the  rupture  is  low  in  the  intestinal  tract, 
by  establishment  of  a  false  anus.  At  the  duodeno-jejunai  juncture, 
where  lateral  anastomosis  is  impossible,  end-to-end  union  should  be 
attempted;  if  this  proves  impossible,  the  duodenal  end  should  be  closed, 
and  the  upper  end  of  the  jejunum  united  to  the  stomach  by  lateral 
anastomosis  (gastro-jejunostomy,  p.  879).  In  ^Nloynlhan's  case  the 
regurgitation  of  the  bile  and  pancreatic  juice  into  the  stomach  caused 
no  disability.  Meerwein  successfully  supplemented  this  operation 
by  uniting  a  lower  loop  of  the  jejunum  to  the  descending  duodenum 
(anterior  antecolic  duodeno-jejunostomy).  If  the  intestine  is  torn 
loose  from  its  mesentery  at  any  point,  it  should  be  resected;  it  will 
be  best  then  to  fix  the  intestinal  loops  in  the  wound,  en  canon  de 
fusil  (p.  834),  after  ligating  their  ends  and  establishing  a  lateral  anasto- 
mosis, as  advised  in  cases  of  resection  for  strangulated  hernia.  Irriga- 
tion should  not  be  employed,  even  if  there  is  fecal  extravasation. 
A  large  rubber  or  glass  drainage  tube  should  be  carried  to  the  floor  of 
the  pelvis,  and  subsequent  treatment  should  be  conducted  as  in  cases 
of  peritonitis. 

Liver.— li  injury  of  the  liver  is  suspected,  the  incision  should  be 
made  through  the  upper  right  rectus.  As  the  blood-pressure  in  the 
liver  is  low,  hemorrhage  is  not  difficult  to  control  if  the  site  of  rupture 
is  accessible.  If  possible,  the  injury  should  be  sutured.  Mattress 
sutures  of  chromic  catgut  will  hold  in  most  cases,  if  they  are  not  drawn 
too  tightly.  If  they  cut  out,  they  should  be  tied  over  strands  of 
catgut,  used  as  the  quills  in  the  old-fashioned  quill  suture  (Fig.  105). 
If  direct  suture  proves  impossible,  the  omentum  may  be  sutured  into 
the  rupture,  as  a  tampon,  or  gauze  may  be  used.  Blood-clots  should 
be  scooped  out  of  the  pelvis  and  spinal  gutters,  or  wiped  up  with 
sponges;  but  irrigation  is  not  advisable.  The  pelvis  should  be  drained, 
and  subsequent  treatment  conducted  as  in  peritonitis.  The  mortality 
after  operation  is  from  75  to  80  per  cent.  (Boljarski). 


844  ABDOMINAL  SURGERY  IN  GENERAL 

Spleen. — The  incision  is  best  made  in  the  upper  left  rectus  muscle. 
The  operative  mortality  is  about  38  per  cent.,  but  many  patients  die 
before  operation  can  be  undertaken.  If  the  spleen  is  not  much  dis- 
organized, it  may  be  possible  to  suture  the  rent,  or  to  tampon  it,  or 
even  to  compress  the  spleen  against  the  diaphragm  by  firmly  applied 
gauze  packs;  but  suture  is  difficult,  owing  to  the  friability  of  the  splenic 
pulp,  and  in  many  cases,  especially  if  the  lesion  is  at  all  extensive, 
splenectomy  (p.  957)  should  be  done.  Sheldon  (1910),  as  the  result  of 
animal  experimentation,  advises  clamping  tbe  pedicle  of  the  spleen 
with  rubber-covered  forceps;  these  are  loosened  in  four  hours,  and 
if  hemorrhage  does  not  recur  they  are  subsequently  removed.  The 
splenic  wound  itself  is  ignored.  This  method  is  more  applicable  to 
cases  of  stab  wound  than  to  rupture,  since  the  spleen  often  is  quite 
disorganized  in  the  latter  cases. 

Stab  Wounds  of  the  Abdomen. — The  symptoms  alone  are  not  suffi- 
ciently characteristic  to  warrant  a  diagnosis.  They  are  those  of  any- 
abdominal  injury:  shock,  vomiting,  pain,  and  rigidity.  The  important 
question  to  decide  in  these  cases  is  whether  or  not  the  abdominal 
cavity  has  been  penetrated.  Under  no  circumstances^  should  this 
be  left  in  doubt  until  the  development  of  peritonitis  renders  it  certain. 
The  question  as  to  which  viscus  is  injured  is  of  quite  secondary  impor- 
tance. If  protrusion  of  omentum,  prolapse  of  bowel,  or  escape  of  intes- 
tinal contents  renders  the  fact  of  penetration  certain,  no  hesitancy 
need  be  felt  in  freely  opening  the  peritoneal  cavity.  This  should  be 
done  by  a  para-median  incision. 

If  the  external  wound  is  small,  and  there  is  doubt  as  to  whether 
the  blade  actually  has  entered  the  peritoneal  cavity,  cautious  explora- 
tion should  be  undertaken.  The  wound  should  not  be  explored  by 
sound  or  finger.  It  should  be  stuffed  with  gauze  and  the  patient 
should  be  prepared  as  for  an  abdominal  operation.  The  surgeon 
should  then  dissect  down  layer  by  layer  and  thus  follow  the  tract 
of  the  wound.  If  difficulty  is  experienced  in  tracing  a  small  stab 
wound,  it  is  best  first  to  lay  bare  the  abdominal  aponeurosis  (sheath 
of  rectus,  aponeurosis  of  external  oblique)  over  a  wide  area,  and 
search  it  for  the  stab  wound.  If  this  cannot  be  found,  and  it  is  known 
that  the  blade  was  very  short  (that  of  a  pen-knife,  for  example),  and 
if  there  are  no  other  symptoms  of  penetration,  the  skin  incision  may 
now  be  closed.  If,  however,  it  be  ascertained  that  the  blade  has  pene- 
trated the  aponeurosis,  the  surgeon  should  next  lay  bare  the  trans- 
versalis  fascia  and  peritoneum,  but  should  not  open  the  latter  until 
he  is  sure  it  has  been  penetrated.  I  am  thus  insistent  upon  this  cautious 
approach  to  the  peritoneal  cavity,  when  the  fact  of  its  penetration 
is  in  doubt,  because  it  often  happens  on  opening  the  abdomen  widely 
in  these  cases  that  inspection  shows  no  evidence  of  intra-abdominal 
lesion,  and  very  extensive  search  becomes  necessary  to  exclude  the 

1  ThL<5  statement,  of  course,  does  not  refer  to  wounds  received  in  warfare. 
These  require  the  same  treatment  as  abdominal  gimshot  wounds  in  military  life 
(p.  191). 


INJURIES  OF  THE  ABDOMEN  845 

possibility  of  visceral  injury;  and  it'  none  be  found  to  exist,  and  it 
is  shown  that  the  vuhierating  weapon  itself  never  had  opened  the 
peritoneal  cavity,  the  surgeon  will  have  subjected  his  patient  to  a 
quite  unnecessary  and  by  no  means  trivial  operation.  If,  however, 
the  fact  of  abdominal  jxMietration  has  been  determined  by  the  method 
just  described,  the  surjivon  will  be  quite  justified  in  his  extensive 
intra-abdominal  manipulations,  even  though  no  lesion  be  found  more 
serious  than  hemorrhage  from  an  omental  vein  (Deaver  and  Ashhurst). 

If  some  of  the  abdominal  contents  protrude  through  a  wound 
their  condition  will  determine  their  proper  treatment.  If  viable,^ 
they  should  be  cleansed,  any  visceral  wounds  should  be  repaired, 
and  the  viscera  should  be  replaced.  For  this  purpose  it  may  be  neces- 
sary to  enlarge  the  abdominal  wound.  Omentum  which  protrudes 
from  an  abdominal  wound  should  be  excised,  as  should  portions  of 
prolapsed  intestine  which  appear  certain  to  become  gangrenous. 

The  abdominal  structures  most  often  wounded  are  the  following: 
small  intestine,  colon,  omentum  or  mesenteries,  liver,  stomach,  and 
diaphragm. 

After  opening  the  abdomen,  the  first  thing  to  do  is  to  control  hemor- 
rhage. Each  intestinal  lesion  should  be  repaired  as  it  is  discovered, 
and  should  not  be  put  aside  with  the  idea  of  repairing  it  later  in  the 
operation.  Careful  search  of  the  entire  intestinal  tract  is  necessary, 
as  the  lesions  often  are  multiple,  and  in  about  one-third  of  the  cases 
which  terminate  fatally  postmortem  examination  shows  this  result 
to  be  due  to  the  presence  of  one  or  more  perforating  wounds  which 
were  not  discovered  at  operation.  The  general  mortality  after  opera- 
tion is  about  50  per  cent.;  it  is  much  higher  if  no  operation  is  done. 
When  operation  is  done  within  the  first  twenty-four  hours  the  mortality 
is  less  than  10  per  cent. 

Gunshot  Wounds  of  the  Abdomen. — In  addition  to  the  general 
account  of  these  injuries  given  in  Chapter  VII,  some  more  particular 
account  of  the  operative  treatment  may  be  gi\en  in  this  place.  The 
probability  of  penetration  is  so  great  that  in  civil  life  ever}^  case  should 
be  subjected  to  explorator}'  laparotomy  at  as  earh'  an  hour  as  possible. 
The  incision  should  be  made  close  to  the  median  line,  in  that  portion 
of  the  abdomen  injured.  The  wound  of  entrance  of  the  bullet  may  be 
disregarded,  unless  there  is  hemorrhage  through  it  from  a  vessel  in 
the  abdominal  wall;  then  the  wound  of  entrance  should  be  opened  and 
the  bleeding  arrested.  But  it  is  much  better  to  enter  the  abdomen 
through  healthy  structures,  and  at  the  most  convenient  point,  than 
to  make  the  exploration  through  the  infected  bullet  tract.  The  bullet 
wound,  however,  should  be  swabbed  out  with  iodin  (3  per  cent.) 
and  packed  with  gauze. 

Gunshot  wounds  of  the  intestinal  tract  usually  are  perforating,  the 
bullet  producing  wounds  of  entrance  and  exit  in  each  coil  of  intes- 
tine which  it  injures.    Sometimes  as  many  as  four  or  six  perforations 

^  See  Strangulated  Hernia,  p.  768. 


846  ABDOMINAL  SURGERY  IN  GENERAL 

will  be  found  within  a  few  inches  of  each  other  in  one  coil  of  bowel. 
In  such  cases  it  may  be  necessary  to  excise  the  segment  of  gut  wounded; 
but  whenever  possible  suture  should  be  preferred,  and  even  if  the 
repair  of  the  perforations  by  suture  seems  to  cause  some  obstruction 
to  the  lumen  of  the  gut,  I  believe  it  is  better  to  run  this  risk  than  to 
undertake  resection.  The  omentum  may  be  sutured  over  the  damaged 
area,  to  reinforce  the  sutured  perforations;  or  the  damaged  coil  of  bowel 
may  be  fixed  in  the  wound,  to  preclude  damage  from  intraperitoneal 
leakage  of  intestinal  contents,  if  there  is  doubt  about  the  sutures 
holding.  If  the  mesentery  is  so  much  damaged  as  to  impair  the 
vitality  of  a  segment  of  intestine,  resection  can  hardl}^  be  avoided. 
Each  lesion  should  be  repaired  as  it  is  found ;  it  is  only  a  waste  of  time 
to  pass  over  a  perforation  thinking  to  find  and  repair  it  at  a  later 
stage  of  the  operation. 

Gunshot  wounds  of  the  stomach  require  special  mention.  The 
"head-high"  (reversed  Trendelenburg)  posture,  with  a  sand  bag 
under  the  patient's  lower  dorsal  spine,  is  a  great  help  in  exposing  the 
field  of  operation.  The  stomach  is  best  found  by  identifying  first 
the  left  lobe  of  the  liver,  and  passing  the  fingers  from  its  under  surface 
over  the  gastro-hepatic  omentum  on  to  the  anterior  wall  of  the 
stomach.  Usually  there  is  both  a  wound  of  entrance  and  one  of  exit. 
The  wound  first  found  should  be  repaired  at  once.  If  no  other  wound 
is  found  on  the  anterior  wall,  the  gastro-colic  omentum  should  be 
divided,  between  hemostats,  on  the  colonic  side  of  the  gastro-epiploic 
arteries,  and  for  a  distance  at  least  of  three  inches.  The  existence  of  a 
perforation  on  the  posterior  wall  usually  will  be  indicated  by  extrava- 
sation within  the  lesser  peritoneal  cavity.  W.  Martin  (1907)  found 
that  among  the  cases  he  studied  failure  to  suture  the  bullet-hole  in 
the  posterior  gastric  wall  had  not  materially  influenced  the  mortality. 
A  perforation  should  be  sutured  if  found;  if  inaccessible  from  the 
posterior  wall  of  the  stomach  the  surgeon  may  open  the  anterior  wall 
of  this  organ  and  suture  the  posterior  perforation  from  inside  the 
stomach.  If  more  room  is  required  to  expose  a  perforation  in  the 
cardiac  region  of  the  stomach,  temporary  resection  of  the  costal 
margin  may  be  adopted;  if  the  line  of  section  is  kept  in  the  cartilages 
(not  invading  the  bony  structure  of  the  ribs),  the  pleural  cavity  will 
not  be  opened  (Auvray).  Drainage  of  the  lesser  peritoneal  cavity 
should  be  secured  by  a  wick  of  gauze  emerging  through  the  gastro- 
colic omentum;  hemorrhage  from  this  structure,  which  has  been  con- 
trolled during  operation  by  hemostats,  is  permanently  arrested  by 
suture.  Drainage  through  the  left  loin  seldom  is  required;  but  some 
form  of  drainage  of  the  lesser  peritoneal  cavity  never  should  be 
neglected,  particularly  in  cases  where  the  pancreas  has  been  injured. 
Another  drain  should  be  placed  anterior  to  the  stomach,  and  in 
cases  where  gastric  or  intestinal  contents  have  been  diffused  in  the 
abdomen,  the  pelvis  should  be  drained  also  through  a  suprapubic 
opening. 

Gunshot  wounds  of  the  duodenum  are  rare,  scarcely  ever  uncompli- 


IXJl  h'IKS  OF   THE  AHDOMEM  847 

cated  l.y  <,tluT  K'si„ns  an.l  usually  fatal.  Proper  exposure  is  difficult 
an.l  It  may  hv  nnpossihle  to  suture  or  even  to  discover  a  perforation 
on  the  retroperitoneal  surface.  Usually  it  will  be  well  to  drain  the 
suturcl  area  especially  if  it  is  retroperit<.neal.  Drainage  ahva  vs  should 
be  employed,  preferably  throuj^h  the  loin,  if  a  retroperitoneal  perfora- 
tion IS  suspecte.1  but  not  definitely  located,  or  if  one  is  located  in 
an  maccessible  p.>s,tion.  Ke.section  with  end-to-end  ana.stomosis  may 
be  required  n  many  instances  it  probably  will  be  safer  to  close 
both  ends  of  the  duodenum,  and  do  gastro-jcjunostomv  or  duodeno- 
jejunostomy  (Deaver  and  Ashhurst). 

•  r!lf  ^?-V''',""'^?  ''^}^''  ^''''  "f*^"  ^>'^^fi  profu.seIy.  There  usually 
IS  httle  difficulty  m  checking  bleeding  by  suture  or  tampon,  and  if 
hemorrhage  is  arrested  in  good  time,  the  immediate  prognosis  is 
reasonably  good;  though  secondary  complications,  such  as  hepatic 
or  subpiirenic  abscess,  empyema,  or  pneumonia,  are  much  to  be 
feared.  Ihe  general  mortality  after  operation  is  from  35  to  40  per 
cent.;  in  a  series  of  37  cases  uncomplicated  bv  injuries  of  other 
viscera,  the  mortality  was  only  16  per  cent.  (Patel  and  Loaec,  1912) 
(runshot  wovmds  of  the  .spleen,  as  in  the  case  of  subcutaneous 
injuries,  frequently  cause  so  much  disorganization  as  to  require 
splenectomy.  ' 

Gunshot  wounds  of  the  pancreas  almost  alwa^•s  are  complicated 
by  injuries  of  surrounding  viscera.  The  best  exposure  is  gained 
through  the  gastro-colic  omentum.  Tamponade  is  more  successful 
than  attempts  at  suture.  Drainage  always  should  be  emploved  If 
the  injury  is  undiscovered,  death  is  practicallv  certain.  ThV  death 
rate  after  operation  is  about  43  per  cent.  (Diehl,  1911) 


CHAPTER   XXIII. 
SURGERY  OF  THE  GASTRO-IXTESTIXAL  TRACT. 

SURGERY  OF  THE  APPENDIX  VERMIFORMIS. 

Appendicitis. — Inflammation  of  the  vermiform  appendix  of  the 
cecum  is  the  most  frequent  form  of  abdominal  disease  seen  by  the 
surgeon.  Its  s\Tnptoms  were  described  even  by  authors  of  classic 
times;  but  no  one,  except  perhaps  Melier,  in  1S27,  considered  disease 
of  the  vermiform  process  as  the  chief,  if  not  the  sole  cause  of  these 
symptoms  until  it  was  proved,  about  thirty  years  ago,  by  IMatter- 
stock  in  Germany  that  almost  aU  abscesses  in  the  right  iliac  fossa 
were  associated  with  a  perforated  appendix;  and  by  Fitz  in  America 
that  in  cases  of  so-called  typhlitis  (inflammation  of  the  cecum)  and 
in  cases  of  appendicitis  the  symptoms  were  identical.  The  term 
appendicitis  was  introduced  by  Fitz  in  1886. 

Pathogenesis. — The  anatomy  of  the  appendix  predisposes  it  to 
inflammation.  It  is  filled  with  fecal  matter  charged  with  bacteria; 
it  contains  a  long  mucous  canal  which  opens  by  a  narrow  orifice  into 
the  cecum;  usually  it  is  more  or  less  kinked  or  twisted,  owing  to  the 
shape  of  its  mesentery;  and  the  slightest  swelling  of  its  walls  at  any 
point  may  cause  complete  obliteration  of  its  lumen,  converting  its 
distal  segment  into  a  closed  cavity  whose  naturally  infectious  con- 
tents are  thus  markedly  increased  in  virulence.  In  addition  to  these 
factors,  the  appendix  possesses  a  precarious  blood-supply :  it  possesses 
no  collateral  circulation;  its  arteries  are  "end-arteries;"  and  the 
slightest  swelling  or  constriction  or  kinking  of  the  organ  may  cut 
oft'  the  blood-supply  completely,  resulting  in  partial  or  total  necrosis. 

The  infection,  in  the  vast  majority  of  cases,  is  enterogenous;  but 
hematogenous  infection  sometimes  occurs  (p.  850).  In  enterogenous 
infection  the  bacteria  swarming  in  the  fecal  contents  of  the  appendix 
produce  a  sub-epithelial  reaction,  which  is  known  as  the  primary 
focus  (Frimarinfekt)  of  Aschoff  (1908).  This  occiu-s  in  the  depths  of 
one  of  the  mucous  crypts  of  the  appendix,  and  consists  of  a  collection 
of  neutrophile  leukoc\"tes.  The  epithelium  itself,  which  overlies  the 
primary  focus,  may  be  destroyed  very  early  in  the  process,  its  place 
being  taken  by  a  plug  of  fibrin.  Usually  a  number  of  these  primary 
foci  develop  simultaneously.  The  inflammatory  reaction  spreads  very 
quickly  toward  the  serous  coat  of  the  appendix,  and  peritonitis  may 
develop  before  the  mucous  surface  is  seriously  diseased.  In  almost 
every  case,  the  primary  infection  is  due  to  the  streptococcus;  but 
invariably  the  colon  bacillus  invades  the  walls  of  the  organ  secondarily, 


APPENDICITIS  849 

and  soon  ovor-fjrows  the  strrptoromis,  so  that  cultures  of  the  latter 
are  lost. 

If  resolution  does  not  occur  at  this  \-ery  early  staf^e  of  ajjjjendicitis, 
these  intranuiral  foci  become  confluent,  and  the  condition  is  known  as 
simple  phlegmonous  appendicitis.  The  existence  of  a  primary  catarrhal 
appendicitis,  with  ulceration  as  its  result,  is  denied  by  Aschoff;  what 
was  formerly  described  as  catarrhal  apjx'ndicitis  is  now  recognized 
as  phle<:;monous  (intramural)  in  nature.  This  phlegmonous  stage  is 
present,  with  few  exceptions,  whenever  the  disease  has  lasted  more 
than  twelve  hours.  Even  should  resolution  occur  at  this  early  stage  of 
the  disease,  the  appendix  will  not  return  to  its  normal  state;  cicatricial 
tissue  remains,  .strictures  may  form,  and  the  organ  is  more  than  ever 
predisposed  to  infection.  If  resolutions  does  not  occur  early  in  the 
phlegmonous  stage  of  the  disease,  intramural  abscesses  develop, 
miliary  in  size.  These  are  prone  to  perforate  the  serous  coat  of  the 
a])pen(lix  {miliary  perforalions),  causing  jicritonitis  without  macro- 
scopic perforation  of  the  appendix.  Or  they  may  rupture  into  the 
lumen  of  the  appendix,  producing  ulcers.  Ulcerative  appendicitis 
never  is  the  primary  stage;  it  follows  the  phlegmonous,  whether  or 
not  this  has  progressed  to  the  stage  of  suppuration.  In  this  ulcerative 
stage  the  mucous  membrane  frequently  is  honorrhagic;  but  the  most 
serious  complications  of  this  stage  are  (1)  ulcerative  perforation  (macro- 
scopic), which  usually  occurs  on  the  anti-mesenteric  border  of  the 
appendix;  and  (2)  necrosis  of  the  wall  of  the  appendix.  This  necrosis 
may  be  the  result  of  anemia  from  vascular  thrombosis,  or  it  may  be 
due  to  the  direct  toxic  influence  of  bacteria  on  the  appendicular  wall. 
In  either  case  secondary  invasion  of  the  necrotic  area  by  putrefactive 
microbes  (from  the  fecal  contents  of  the  appendix)  leads  to  gangrene. 
Separation  of  the  slough  formed  in  this  manner  produces  yet  another 
variety  of  perforation. 

Every  attack  of  appendicitis  passes  through  all  the  stages  described 
unless  arrested  spontaneously  or  unless  the  appendix  is  removed. 

If  resolution  occurs  early  in  the  phlegmonous  stage  of  the  disease, 
and  if  the  appendix  suffers  a  number  of  such  mild  attacks  (which  may 
be  so  mild  as  to  pass  unnoticed),  a  condition  described  as  chronic 
appendicitis  may  develop.^  This  term  implies  not  so  much  a  chronic 
inflammation,  as  defined  at  p.  35,  as  it  does  the  result  of  previous 
inflammatory  attacks.  The  lesions  are  fibrotic  and  sclerotic  in  nature, 
and  are  most  marked  in  the  distal  portion  of  the  appendix,  especially 
behind  a  stricture.  In  some  cases  repeated  mild  attacks  lead  to 
obliteration  of  the  lumen  of  the  organ,  through  the  process  of  adhesion 
between  its  apposed  granulating  walls.  This  appendicitis  obliterans 
(Senn,  1894)  usually  affects  only  the  tip  of  the  organ,  but  as  the  patient 
ages  the  entire  lumen  may  be  obliterated. 

1  This  is  the  teaching  of  Aschoff,  whose  studies  of  the  pathology  of  appendicitis 
are  the  most  recent  and  accurate.  Other  authorities  have  held  that  an  acute 
attack  seldom  occurs  except  in  an  appendix  already  the  seat  of  chronic  appendicitis. 
Both  views  are  harmonized  if  we  admit  that  chronic  appendicitis  alway.s  begins 
with  a  definite  attack  which  is  acute  pathologically,  no  matter  how  mild  chnically. 
54 


850     SURGERY  OF   THE  G ASTRO-INTESTINAL   TRACT 

Strictures,  or  actual  occlusion  of  the  lumen  of  the  appendix  may 
occur  at  \arious  points.  If  a  stricture  only  is  present,  it  is  usual  for 
a  coprolith  or  fecal  concretion  to  develop  behind  it  (Fig.  837),  or 
between  two  strictures.  If  complete  occlusion  exists  the  tip  of  the 
appendix  beyond  the  occlusion  or  the  segment  lying  between  two 
occluded  points  may  become  the  seat  of  an  empyema,  during  an  acute 
attack;  or  if  the  infection  dies  out  a  cyst  may  succeed  the  empyema. 
Not  infrequently  in  an  acute  attack  temporary  occlusion  (from  edema 
or  kinking)  occurs  close  to  the  cecum  and  the  whole  appendix  is  con- 
verted into  an  abscess,  sac.  Fecal  concretions  found  in  the  a})pendix 
at  operation  almost  surely  are  the  result  of  a  previous  attack  of 
appendicitis;  after  they  are  once  formed  they  predispose,  by  their 
mechanical  action,  to  further  attacks  and  especially  to  perforation, 
which  occurs  oftenest  behind  the  concretion.  Foreign  bodies  which 
are  rare  in  the  appendix,  act  in  much  the  same  way  as  do  the  fecal 
concretions:  they  may  lie  in  the  lumen  of  the  appendix  for  years 
without  producing  any  symptoms. 


Fig.  837.  —  Gangrenous  appendix  with  fecal  concretion  near  tip.  Note  thickness 
of  wall«.  indicating  previous  attacks;  stricture  on  proximal  side  of  concretion;  and 
imi)f'ndin{i  perforation  near  tip.     Episcopal  Hospital. 

Causes. — Appendicitis  is  commonest  between  the  ages  of  ten  and 
thirty  years,  when  all  infectious  disorders  are  most  prevalent.  Strep- 
tococci, especially  diplococci,  are  the  bacteria  most  often  directly 
responsible  for  an  attack  of  the  disease;  but  why  it  is  that  they  produce 
the  attack  at  any  given  time  is  a  mystery.  The  great  frequency  of 
enterogenous  infection  has  already  been  noted;  and  it  is  probable  that 
stagnation  of  the  contents  of  the  appendix  from  kinking  is  the  main 
predisposing  cause.  Digestive  derangements  increase  the  virulence 
of  bacteria  in  the  intestinal  canal,  or  are  the  result  of  this  increased 
virulence ;  and  disordered  peristalsis  may  force  fecal  matter  containing 
these  highly  virulent  organisms  into  the  appendix.  There  is  no  good 
proof  that  appendicitis  arises  as  the  extension  into  the  appendix  of  a 
catarrhal  inflammatory  process  in  the  cecum.  It  is  probable  that  intes- 
tinal parasites  found  in  the  appendix  (Fig.  838)  have  no  etiological 
significance. 

In  some  cases  it  is  possible  that  infection  occurs  through  the  blood- 
stream (hematogenous).  In  this  connection  attention  has  been  called 
(by  Kellynack,  Kretz,  and  others)  to  the  histological  resemblance  of 
the  appendix  to  the  faucial  tonsils,  both  of  them  containing  much 
lymphoid  tissue;  and  it  has  been  held  that  appendicitis  is  an  abdominal 
angina.     But   neither   the  clinical  history  of   the  patients,  nor  the 


AI'I'KSDICITIS  851 

liist()l<),<;ic;il  cximiinatioii  of  X\\v  disoast'd  a])i)(MHlicrs  supports  the  theory 
of  heinatoj^euous  infeclion,  except  in  extremely  rare  instances. 

One  attack  of  appendicitis  predisposes  to  another.     Nearly  85  per 
cent,  of  oOOO  |)aticnts  under  Deavcr's  care  bad  bad  a  previous  attack. 


Fig.  838.— Acute  ai)|)("iulicitis,  appendix  containiii};  oxyuiis  vcnniculaiis.    (Xaturu 
size.)     Episcoi>al  Hospital. 

Acute  Appendicitis.  —  Symptoms  and  Clinical  Course.  —  Pain, 
nausea,  and  vojuiiing  followed  by  tenderness  and  rigidity:  These  are 
the  cardinal  symi)toms  of  acute  appendicitis.  Usually  without  pre- 
vious warning-  the  patient  develops  a  sudden  colicky  pain,  more  or  less 
diffused  throughout  the  abdomen  or  localized  to  the  umbilical  region. 
This  pain  is  due  to  the  disordered  peristaltic  action  of  the  appendix 
in  attempts  to  empty  itself  against  resistance.  It  is  analogous  to  the 
pain  of  biliary,  intestinal,  or  renal  colic;  like  them  it  excites  nausea 
and  vomiting.  The  ^•omiting  is  reflex,  and  suffices  only  to  empty  the 
stomach.  It  is  not  repeated  unless  peritonitis  develops,  when  it 
assumes  the  type  already  described  at  p.  806.  This  primary  nausea 
and  vomiting  follows  and  does  not  precede  the  initial  pain  of  appen- 
dicitis; to  this  rule  there  are  very  few  exceptions.  At  this  time  there 
is  no  special  tenderness  in  the  abdomen;  indeed,  as  in  intestinal  colic, 
pressure  "may  relieve  the  pain.  But  usually  within  twelve  hours  the 
character  of  the  pain  changes;  it  is  no  longer  diffuse  and  colicky,  but 
becomes  localized  to  the  right  iliac  region,  where  the  diseased  appendix 
is  found.  The  pain  is  now  burning,  constant,  and  intense.  Simul- 
taneously with  this  localization  of  the  pain  to  the  right  iliac  fossa 
there  develop  both  tenderness  and  rigidity,  which  also  are  confined 
to  the  region  of  the  appendix.  Palpation  now  reveals  a  normal 
abdomen  elsewhere,  but  over  the  right  iliac  fossa  the  muscles  (par- 
ticularly the  right  rectus)  are  rigid,  and  tenderness  is  so  marked  that 
even  slight  pressure  causes  extreme  pain.  This  localized  rigidity  is 
the  most  important  single  symptom  of  appendicitis.  Roughly  speaking, 
all  these  symptoms  of  appendicitis  are  localized  around  McBumey's 
point,  which  was  described  by  its  author  in  1891  as  a  point  from  one 
and  a  half  to  two  inches  distant  from  the  anterior  superior  spine  of 
the  right  ilium  on  a  line  drawn  between  this  spine  and  the  umbilicus. 

When  this  stage  of  the  disease  has  been  reached  it  is  possible  in  all 
but  the  most  exceptional  cases  to  make  an  accurate  diagnosis  of  appen- 
dicitis. The  condition  is  clinically  one  of  localized  peritonitis,  as 
described  at  p.  805,  and  that  this  is  the  pathological  state  is  evident 
from  the  account  of  the  pathogenesis  of  appendicitis  already  given. 


852  SURGERY  OF   THE  GASTRO-INTESTINAL   TRACT 

Appendicitis  is  localized  peritonitis;  all  the  signs  of  this  condition  are 
present :  tenderness  and  rigidity,  arrest  of  peristalsis  in  the  immediate 
vicinity  of  the  lesion,  local  tympany  from  paresis  and  distention  of 
the  ileo-cecal  coil  of  the  intestinal  canal;  and  persistent  constipation. 
The  development  of  complications  should  not  be  awaited  before 
making  an  accurate  diagnosis. 

In  a  small  proportion  of  cases  the  attack  does  not  begin  with  acute 
pain,  but  with  a  gradually  increasing  discomfort  in  the  neighborhood 
of  the  appendix;  and  in  such  cases,  the  physical  signs  of  appendicitis 
often  develop  without  any  nausea  or  vomiting.  Hence  it  is,  that  in 
appendicitis  as  in  all  other  acute  abdominal  lesions  when  the  history 
of  the  case  is  atypical,  it  is  safer  to  rely  on  the  physical  examination 
than  on  the  history,  in  reaching  a  diagnosis. 

No  mention  has  been  made  hitherto  of  the  temperature,  pulse,  or 
leukocytosis,  in  connection  with  appendicitis.  They  are  of_  quite 
secondary  importance.  Usually  the  temperature  is  slightly  elevated 
from  the  first,  and  the  pulse  quickened,  as  in  all  febrile  states.  There 
also  is  leukocytosis  in  most  cases,  the  white  blood  cells  numbering 
anywhere  from  10,000  to  40,000.  The  white-blood  count  is  of  more 
value  in  prognosis  (p.  859)  than  in  diagnosis. 

When  the  stage  of  localized  symptoms  described  above  has  been 
reached,  the  disease  pursues  either  one  of  two  courses:  It  subsides, 
or  complications  develop.  In  the  former  case  the  pain  gradually 
lessens;  the  tenderness  changes  to  mere  "soreness,"  rigidity  disappears, 
flatus  is  passed  normally,  the  temperature  curve  reaches  the  normal, 
and  the  leukocytosis  gradually  subsides.  The  course  of  such  an 
attack  lasts  on  the  average  from  three  days  to  a  week.  If  the  attack 
does  not  subside,  complications  develop;  they  are  frequent  and  almost 
countless.  Among  the  more  important  are  perforation  and  gangrene 
of  the  appendix,  and  abscess  formation  or  diffuse  peritonitis  with 
all  its  dire  consequences.  The  symptoms,  diagnosis,  and  treatment 
of  these  complications  are  considered  at  p.  857. 

Diagnosis. — The  diagnosis  of  appendicitis  usually  is  easy.  It  is 
the  most  frequent  of  all  acute  abdominal  diseases,  and  should  be  ever 
in  the  surgeon's  mind.  In  intestinal  colic  the  pain  is  general  and  does 
not  become  localized  to  the  region  of  the  appendix;  pressure  relieves 
it;  nausea  and  vomiting  are  by  no  means  constant,  and  often  precede 
the  onset  of  the  pain;  active  peristalsis  is  audible;  and  diarrhea  is  the 
usual  outcome.  At  no  period  of  the  attack  is  there  muscular  rigidity. 
Fever  is  unusual.  Leukocytosis  is  absent.  In  biliary  colic  the  pain 
is  situated  in  the  right  hypochondrium  and  often  radiates  to  the 
right  shoulder.  A  history  of  many  previous  attacks  often  is  obtainable, 
and  jaundice  may  have  been  present  at  some  time.  Tenderness  and 
rigidity  if  present  are  confined  to  the  gall-bladder  area.  If  the  patient 
is  past  forty  years  of  age  the  attack  probably  is  biliary,  not  appen- 
dicular. In  acute  cholecystitis  the  symptoms  somewhat  resemble  those 
of  biliary  colic.  Tenderness  and  rigidity  are  constant,  but  are  con- 
fined to  the  upper  right  abdominal  quadrant,  unless  the  gall-bladder 


M'i'i<:si)i('iTis  853 

IS  (lisplaccd.     TIu«  clmnictcrislics  by  vvliicli  ;iii  enlarged  Kull-hladdcr  is 
nc.un.z,-,!  an-  stated  at  p.  <)L'().      Jn  renal  colic  from  disease  of  the 
right  kidney,   the  symptoms  may  elosely  simulate  those  of  ai)peii- 
dieitis,  particularly  when  a  ealcuhis  is  lod^vd  j,,  the  ureter      Yet  tlie 
ra(hatiou  of  tlie  pain,  the  urinary  HikHuks,  aii<l  tiie  absenee  of  gastro- 
iiitestinal  symptoms  suffice  lu  most  cases  to  make  the  diagnosis  clear 
Skiagrapliy  is  a  vahiabie  aid.     In  acute  salpinqiiis,  especially  affecting 
tlie  right  tube,  the  peritoneal  symptoms  are  confined  to  \he  pelvis 
uiK    gastro-mtestmal  symptoms  are  absent.     Tenderness  is  too  low 
and  too  near  the  median  line,  for  appendicitis;  it  is  not  at  McBurnev's 
pomt,  but  about  over  the  middle  of  Poupart's  ligament.     Vaginal 
examination   confirms  the   diagnosis.     Some   cases   of  typhoid  fever 
begin  with  rather  acute  abdominal  i)ain,  and  this  mav  be  accompanied 
by  nausea  and  vomiting.     I'sually,  however,  strici  inquirv  reveals 
that  the  actual  onset  of  the  disease  occurred  several  da^'s  previously 
with  niahuse,  headache,  feverishness,  etc.     The  tem]3erature  is  too 
high  (  ().]     l^   or  more)  and  the  pulse  too  slow   (]()()  or  lower)  for 
appendicitis;  and  there  is  leukopenia  not  leukocytosis. 

In  none  of  the  affections  mentioned,  nor  in  any  of  the  score  or  more 
other  diseases  which  may  be  exceptionally  confused  with  appendicitis, 
is  the  clinical  history  typical  of  the  latter:  midden  pain,  first  diffuse 
then  settling  to  the  right  iliac  ioH^a;  followed  bv  vomiting;  and  the 
extremely  important  localized  tenderness  and  rigidity. 

Prognosis.— The  appendix  is  the  fons  et  origo  mall,  and  if  it  is 
removed   before  complications  develop,   the    prognosis    is   brilliant 
1  he  mortality  of  operation  at  this  stage  of  the  disease  is  so  low  that 
hundreds  and  hundreds  of  such  simple  cases  are  cured  without  a  death 
Once  m  se^■eral  hundred  operations  it  may  happen  that  a  patient  dies 
of  pneumonia  or  some  other  unforeseen  complication;  but  this  minimal 
risk  stands  in  no  sort  of  relation  with  the  risk  run  bv  delaying  operation 
to  determine  whether  or  not  complications  are  about  to  develop. 
As  a  matter  of  fact,  even  under  the  most  approved  non-operative  treat- 
ment  complications  develop  in  at  least  10  per  cent,  of  cases.    It  was 
justifiable  to  delay  operation  only  in  the  thiNs  before  the  develop- 
ment of  aseptic  surgery;  until  that  time  the  onlv  form  of  intra-abdomi- 
nal disease  successfully  amenable  to  surgical  treatment  was  localized 
suijpuration.     It  was  then  and  it  is  now  absolutely  impossible  to 
contro  the  course  of  the  disease  in  the  appendix  by  anv  means  known 
to  medical  science.^     Unless  the  appendix  is  removed  the  patient  is 
left  to  the  unaided  efforts  of  nature.     Never  should  the  surgeon  call 
for  aid   from   beneficent   Nature   until    he    has  exhausted   his   own 
resources.     Apollo  would  not  help  the  teamster  until  the  latter  had 
whipped  up  his  horses  and  put  his  own  shoulder  to  the  wheel.    The 
mere  diagnosis  of  appendicitis  should  be  an  indication  for  immediate 
operation.     I  am  conceited  enough  to  believe  that  I  can  recognize, 
as  well  as  anyone  else,  the  occurrence  of  perforation  or  suppuration 

of  \his  disiS?'"^  ""^  "^'^^^^  ^"^  '^^  «ppenrfe,  not  of  the  peritoneal  complications 


854 


SURGERY  OF   THE  GASTRO-INTESTINAL   TRACT 


in  appendicitis,  l)ut  I  frankly  confess  my  ntter  ina})ility  to  feel  sure 
one  hour  that  neither  of  these  events  will  occur  durinji;  the  next,  so 
long  as  an  acutely  inflamed  appendix  remains  within  a  patient's  belly. 
It  is  possible  to  argue  on  probabilities,  and  to  defer  ojjcration  in  cases 
that  appear  mild;  but  sooner  or  later  the  surgeon  will  encounter  a 
case  which  will  make  him  regret  his  procrastination,  and  will  C()n\ince 
him  that  he  has  lost  the  life  of  his  patient  through  over-conhdence 
in  his  own  powers  of  prognostication.  Even  if  life  be  not  lost,  it 
will  be  surely  jeopardized  by  the  development  of  peritonitis,  localized 
or  diffused,  with  the  possibility  of  its  lethal  sequels,  such  as  gangrene 
of  the  bow^l,  intestinal  obstruction,  pylephlebitis,  etc.  It  is  strange 
that  well-meaning  physicians,  and  even  some  apparently  intelligent 
surgeons  will  delay  operation,  trusting  to  be  warned  of  impending 
danger  by  wTll-defined  symptoms  in  time  to  employ  an  operation, 
when  the  best  time  for  operation  is  before  alarming  symptoms  arise. 
Only  in  the  very  aged,  or  in  those  with  extremely  serious  visceral  lesions 
(cardiac  or  renal)  is  delay  justifiable. 

Treatment. — The  abdomen  should  be  shaved  and  cleansed  and 
the  bladder  emptied  (by  catheter  if  necessary)  as  before  any  abdominal 
operation.  No  other  preparation  is  required,  but  in  many  cases  it  is 
well  to  empty  the  lower  bow^el  by  enema. 

Operation. — I  prefer,  and  habitually  employ,  the  transverse  incision 
of  G.  G.  Davis.    Other  incisions  for  appendectomy  have  been  described 

in  Chapter  XXII.  This  transverse 
incision  is  so  planned  that  its  centre 
lies  over  the  right  semilunar  line,  at 
the  le\el  of  the  anterior  superior 
spine  of  the  ilium.  In  simple  acute 
cases  the  incision  is  from  one  and  a 
half  to  two  inches  long  (Fig.  839). 
The  skin  and  subcutaneous  tissues 
are  divided,  exposing  the  aponeurosis 
of  the  external  oblique.  This,  and 
the  anterior  sheath  of  the  rectus  are 
incised  in  the  same  transverse  direc- 
tion throughout  the  inner  half  of 
the  wound.  The  muscle  fibres  of  the 
rectus  are  thus  exposed,  and  are  to 
be  retracted  toward  the  middle  line. 
In  this  way  the  posterior  sheath  of 
the  rectus  and  the  trans^'ersalis 
fascia  are  exposed.  The  peritoneal 
cavity  is  next  opened  in  the  usual  way,  in  a  transverse  direction.  The 
left  forefinger  is  then  inserted  into  the  peritoneal  cavity,  and  hooks 
up  the  abdominal  wall  on  the  outer  side  of  the  opening  already  made. 
With  blunt  scissors  the  operator  then  splits  the  internal  oblique  and 
transversalis  muscles  outward  in  the  direction  of  their  fibres  (which 
here  run  directly  trans\'ersely),  thus  passing  ])arallel  to  the  motor 


Fig.  839. — Transverse  incision  for 
appendectomy ;  two  weeks  after  opera- 
tion.    Episcopal  Hospital. 


Ari'ESDicrns  855 

nerves  of  tlie  abdominal  wall.  'I'lu-  transversalis  fascia  and  perito- 
neum are  then  eut  in  the  same  direction,  throu<,diout  the  whole  extent 
of  the  wound.  If  more  room  is  needed  toward  the  median  line,  the 
anterior  and  posterior  sheaths  of  the  rectus  may  be  incised  as  far  as 
the  linea  alba,  but  the  muscle  itself  need  not  be  cut,  as  it  can  be 
drawn  far  to  the  left  with  a  retractor.  If  more  room  is  needed  to  the 
outer  side,  the  oblitiue  and  transversalis  muscles  may  be  cut  as  far 
as  the  iliac  spine,  or  further  if  necessary,  without  any  damage  to  the 
abdominal  nerves.  Some  branches  of  the  deep  circumflex  iliac  artery 
may  be  cut  if  the  wound  is  extended  outward,  but  the  only  muscular 
fibres  which  will  be  cut  across  are  those  of  the  external  ol)li(iue;  but  in 
mo.st  cases  the  inc'sion  involves  only  the  aponeurosis  of  this  muscle, 
not  its  muscular  fibres. 

Locating  the  Appendix. — First  Method. — Place  two  fingers  of  the 
left  hand  inside  the  abdominal  wound  and  follow  the  parietal 
peritoneum  of  the  anterior  alxlominal  wall  downward  to  Poupart's 
ligament;  then  carry  the  fingers  upward  along  the  brim  of  the  pelvis 
(recognized  by  the  pulsations  of  the  external  iliac  artery)  until  they 
are  arrested.  The  structure  which  arrests  them  will  be  the  mesentery 
of  the  ileo-cecal  region.  Usually  the  appendix  can  be  recognized  in 
this  position  by  the  sense  of  touch,  and  if  not  adherent  can  be  drawn 
out  of  the  abdominal  wound  betw^een  the  index  and  middle  fingers. 
Second  method:  Pass  the  fingers  of  the  left  hand  along  the  parietal 
peritoneum  on  the  outer  side  of  the  wound,  and  let  them  follow  the 
parietal  peritoneum  inw^ard  across  the  iliac  fossa.  The  structure 
which  arrests  them  will  be  the  cecum  or  ascending  colon  with  its 
mesentery.  Draw  the  cecum  into  the  wound  and  trace  its  longitu- 
dinal bands  downward  until  they  converge  at  the  base  of  the  appendix 
which  is  then  delivered.  Third  method:  This  is  less  brilliant  than 
those  just  mentioned,  but  it  is  the  surest  method  of  all.  Pack  all  the 
abdominal  contents  to  the  patient's  left,  by  inserting  gauze  sponges. 
When  all  the  movable  structures  have  been  thus  carried  away  from 
the  seat  of  operation,  only  the  immovable  will  remain.  This  is  the 
cecum,  attached  to  the  posterior  abdominal  wall  by  its  short  mesen- 
tery. When  the  cecum  is  thus  found,  draw  it  out  of  the  wound,  and 
trace  it  downward  until  the  appendix  is  delivered. 

Removal  of  the  Appendix. — (1)  Pass  an  aneurysm  needle,  carrying 
No.  1  chromic  catgut,  through  the  meso-appendix  close  to  the  base  of 
the  appendix  and  tie  this  ligature  around  the  free  border  of  the  meso- 
appendix  as  far  away  from  the  appendix  as  possible.  If  the  meso- 
appendix  is  very  thick  or  long,  it  is  safer  to  tie  it  in  two  or  three 
sections.  (2)  Cut  the  meso-appendix  as  close  to  the  appendix  as  pos- 
sible, thus  leaving  enough  tissue  beyond  the  ligature  to  prevent  its 
slipping  (Fig.  841).  (3)  Clamp  the  appendix  at  its  juncture  with  the 
cecum,  and  clamp  it  again  about  a  centimeter  distant.  Remove  the 
first  clamp  and  ligate  the  base  of  the  appendix  in  the  groove  crushed 
by  the  clamp,  using  No.  1  cliromic  catgut  (Fig.  842).  (4)  Cut  the 
appendix  between  the  ligature  and  the  distal  clamp.     The  stump  of 


856 


SURGERY  OF   THE  GASTRO-INTESTINAL   TRACT 


the  appendix  may  he  touched  with  phenol  and  with  alcohol,  but  I 
regard  this  as  an  unnecessary  refinement  of  technique.     (5)  Insert 


Fig.  840. — The  blood-sui)i)Iy  of  the  cefuni  and  appendix. 


Fig.  841. — Appendectomy:  the  nieso-  Fig.  842. — Appendectomy:  the  base  of 

appendix  has  been  tied  close  to  the  base  tlie    appendix    has    been    ligated    in    the 

of  the  cecum,  and  then  divided  close  to  groove  made  bv   clamping  a  hemostat;  a 

the  appendix.  second  hemostat  is  left  in  place. 

a  purse-string  suture  of  linen  thread  in  the  cecum  about  2  cm.  away 
from  the  stump  of  the  appendix  (Fig.  S43) ;  then  cut  the  ends  of  the 
appendicular   ligature  short,  and  as  the   stump  of  the  appendix  is 


COMPLICATIOXS  OF   APPENDJCiriS 


S57 


jK'ritoiieiim   and  pos- 
slieatli  of   tlic  rectus 


Fi(!.  843. — Appendectomy:  the  ap- 
pendix has  been  cut  off,  and  a  purse- 
string  suture  has  been  inserted  in  the 
cecum. 


pushed  inward,  tie  tlie  purse-string  suture,  thus  completely  burying 
the  stumj).  (())  Look  at  the  meso-ap|)endix  to  make  sure  that  the 
lif^ature  has  not  slii)pe(l,  and  then  cut  the  lifjature  short.  (7)  Finally, 
close  tlie  abdominal  wound,  suturing  (//)  the 
terior  sheath  of  the  rectus;  (6)  the  anterior 
and  the  internal  oblique  and  trans- 
ver.salis  muscles;  (c)  the  external 
oblique  aponeurosis.  Each  layer  is 
sutured  with  a  continuous  suture 
of  chromic  catgut.  Tie  any  bleed- 
ing points  in  the  superficial  fascia; 
and  then  close  the  skin  wound 
with  interrupted  sutures  of  silkworm 
gut. 

In  vnroniplicdted  cases  of  appen- 
dicitis no  drainage  is  required,  and 
no  special  after-treatment  is  to 
be  pursued.  The  patient  may  have 
hot  water,  in  amounts  of  a  half 
ounce  (15  c.c.)  or  less,  every  fifteen  to 

thirty  minutes,  by  mouth,  after  twelve  hours.  Liquid  diet  is  begun 
after  twenty-four  hours  and  is  continued  for  three  days,  when  soft 
diet  is  allowed.  Full  diet  may  be  given  after  the  tenth  day,  wdien  the 
wound  is  first  dressed  and  the  skin  sutures  removed.  If  the  bowels 
do  not  move  spontaneously  by  the  third  or  fourth  day,  an  enema  should 
be  given,  and  only  when  this  proves  ineft'ectual  is  a  purge  required. 
I  prefer  to  keep  my  patients  in  bed  at  least  two  weeks,  but  many 
surgeons  allow  them  to  be  up  in  a  week  or  ten  days. 

If  operation  cannot  be  done,  then,  so  soon  as  a  diagnosis  is  made, 
treatment  should  be  instituted  as  already  advised  for  cases  of  difi^use 
peritonitis  (p.  810).  By  adherence  to  the  strictest  code  of  the  Ochsner 
treatment,  it  usually  will  be  possible  to  prevent  the  development  of 
widespread  peritonitis;  but  even  under  the  best  circumstances,  an 
abscess  will  form  or  some  other  complication  develop  in  about  10 
per  cent,  of  cases.  Nothing  is  so  surely  productive  of  complications  as 
the  adminisiraiion  of  purgaiives. 

Complications  of  Appendicitis. — From  a  clinical  point  of  ^•iew  the  most 
frecpient  complications  of  appendicitis  are  abscess,  diffuse  peritonitis, 
and  gangrene  of  the  appendix.  There  is  no  greater  fallacy  than  to 
suppose,  as  is  done  by  many  physicians,  that  neither  abscess  nor 
peritonitis  can  occur  unless  there  is  a  macroscopical  perforation  of 
the  appendix.  Macroscopical  perforations  are  comparatively  rare, 
and  even  when  present  usually  are  of  secondary  importance  to 
the  abscess  or  the  diffuse  peritonitis  which  dominates  the  clinical 
picture. 

Among  the  complicated  cases  of  appendicitis  under  my  own  care, 
the  following  lesions  ha\e  been  the  cause  of  the  predominating 
symptoms : 


858 


SURGERY  OF   THE  GASTRO-INTESTINAL   TRACT 


Primary  abscess in  19.1  percent. 

Residual  abscess 11.2       " 

Gangrene 24.7       " 

Diffuse  peritonitis      ....         44.9       " 


Mortality.  . 

0.0  per  cent. 
20.0 

13.6        " 
17.5 


The  general  mortality  for  the  ientire  series  of  complicated  cases  of 
appendicitis  is  I'A.o  per  cent.     Not  one  of  these  patients  would  have 

died  if  operation  had  been  done 
within  twenty-four  hours  of  the 
onset  of  the  disease,  and  even 
those  patients  among  the  com- 
plicated cases  who  recovered 
would  have  been  saved  the 
discomforts  and  prolonged  con- 
valescence attending  a  drained 
wound. 

Primary  Appendicular  Ab- 
scess.— This  is  the  least  dan- 
gerous of  the  complications  of 
appendicitis.  The  reaction  of 
the  peritoneum  to  the  appen- 
dicular infection  is  adequate, 
and  the  infection  remains  local- 
ized to  the  immediate  neigh- 
borhood of  the  appendix.  The 
most  frequent  site  of  such  ab- 
scess is  in  the  right  iliac  fossa\ 
Other  frequent  sites  are  the 
pelvis  and  the  right  flank  or 
loin,  depending  upon  the  posi- 
tion of  the  appendix  (Fig.  844).  An  abscess  on  the  median  side  of 
the  cecum,  or  among  the  coils  of  small   intestines  is  unusual;  one 


Fig.  844. — Usual  sites  of  appendicular 
abscess:  1,  in  the  right  iliac  fossa;  2,  in 
the  pelvis;  3,  in  the  right  kidney  pouch. 


v:!-- 


FiG.  845. — Perforated  appendix,  forming  part  of  an  abscess  wall;  perforation 
into  adhesions.     Episcopal  Hospital. 

between- the  layers  of  the  mesentery  of  the  ileum,  or  elsewhere  in 
the  retroperitoneal  tissues,  is  very  rare.  In  most  cases  the  wall  of  the 
abscess  is  formed  by  the  parietal  peritoneum  of  the  iliac  fossa,  pelvis 


A  PPENDICULA R   A BSCESS 


859 


or  flank,  on  one  side;  l)y  tlu-  cociiiii,  adherent  omentum  or  anterior 
abdominal  wall,  in  front ;  while  its  medial  wall  is  formed  by  omentum 
or  eoils  of  small  intestine.  The  appendix  usually  forms  a  part  of  the 
abseess  wall  at  some  point  (Fig.  S4')),  but  may  lie  entirely  within  the 
abscess  cavity.  It  may  or  may  not  present  a  maeroscopical  perforation. 
St/niptoms. — So  long  as  the  pus  is  under  tension  there  are  the  usual 
symptoms  of  toxic  absorption,  such  as  elevation  of  temperature, 
increase  in  the  pulse  rate,  and  leukocytosis.  If  a  differential  count 
shows  more  than  DO  per  cent,  of  the  white-l)lood  cells  are  i)olymicleated, 
it  usually  indicates  the  presence  of  pus  provided  there  is  hyperleuko- 
cytosis.  A  high  white  count,  with  a  low  polynuclear  percentage, 
indicates  ])()or  resistance  on  the  j)art  of  the  j^atient.  If  leukocytosis 
is  not  marked  and  the  polynuclear  percentage  is  low,  it  indicates 
either  that  the  abscess  is  completely  localized  and  that  no  absorption 
is  occurring,  or  that  the  patient  is  overwhelmed  by  the  infection. 
The  clinical  picture  must  be  relied  upon  to  distinguish  between  these 
two  states.  When  only  a  small  abscess  has  formed,  and  has  become 
well  localized  so  that  no  absorption  is  occurring,  a  careless  observer 
may  be  led  to  think  that  the  patient  has  entirely  recovered.  In  such 
cases  secondary  leakage  of  the  abscess  may  occur,  resulting  in  diffuse 
peritonitis. 


Fig.  846. — Large  appendicular  abscess  two  weeks  after  onset.     X  on  anterior  superior 
spine  of  ilium.    Outlines  of  abscess  indicated  by  a  drainage  tube.    Episcopal  Hospital. 

The  physical  signs  present  depend  upon  the  duration  of  the  abscess 
and  upon  its  size.  Soon  after  the  formation  of  an  abscess,  the  rigidity 
and  tenderness  so  characteristic  of  appendicitis  in  its  earlier  stages 
may  persist  to  such  a  degree  that  recognition  of  a  mass  by  palpation 
may  be  impossible.  But  by  percussion  it  usually  is  possible  to  demon- 
strate an  area  of  dulness  in  the  right  iliac  fossa.  Such  dulness,  however, 
frequently  is  due  to  a  mass  of  adherent  omentum;  and  it  is  not  safe 
to  assume  that  a  mass,  even  if  distinct  and  papable,  contains  much 
pus.  The  quantity  of  pus  may  vary  from  a  few-  drops  up  to  a  pint 
or  more.  Seldom  does  the  abscess  contain  more  than  10  to  15  c.c. 
of  pus.  Palpation  through  the  rectum  may  discover  a  bulging,  tender 
mass  in  the  rectovesical  pouch,  or  in  women  behind  the  uterus  Rectal 
touch  is  particularly  valuable  in  small  children,  for  in  them  a  large 
pelvic  abscess  may  pass  unnoticed  if  this  examination  is  neglected. 


S60  SURGERY  OF   THE  GASTRO-INTESTINAL   TRACT 

If  the  appendicular  abscess  has  been  in  existence  for  several  days,  it 
usually  is  possible  to  define  its  outlines  by  palpation,  and  in  cases  of 
very  long  duration  the  abscess  may  be  visible  at  a  glance  as  a  large 
rounded  tumor  (Fig.  846). 

Residual  Appendicular  Abscess. — This  is  one  which  forms  after 
the  subsidence  of  diffuse  peritonitis  caused  by  appendicitis.  It  has 
also  been  termed  a  post-Ochsner  abscess,  because  localization  of  the 
infection  has  been  brought  about  by  adherence  to  the  Ochsner  treat- 
ment (p.  811).  The  pathogenesis,  symptomatology,  and  treatment 
of  these  conditions  have  been  discussed  in  Chapter  XXII. 

Treatment  of  Appendicular  Abscess. — An  appendicular  abscess  should 
be  evacuated,  and  unless  the  patient  is  very  gravely  ill  the  appendix 
should  be  removed  at  the  same  operation.  But  if  it  is  very  difficult 
to  find  the  appendLx,  or  if  it  is  extremely  adherent,  it  need  not  be 
removed.  Deaver  says  it  is  better  to  have  a  live  patient  with  his 
appendix  still  in,  than  a  dead  patient  without  one.  Operation  for 
abscess  should  be  undertaken  as  soon  as  possible  after  the  diagnosis 
is  made.  There  is  nothing  to  be  gained  by  delay,  and  in  many  cases, 
especially  of  residual  abscess,  there  is  danger  that  the  adhesions 
limiting  the  abscess  may  give  away,  and  that  diffuse  peritonitis  may 
follow  the  leakage  of  pus. 

It  is  the  teaching  of  Deaver,  and  many  surgeons  are  in  accord  with 
him,  that  it  is  best  always  to  open  the  appendicular  abscess  at  the 
place  where  it  comes  in  contact  with  the  parietal  peritoneum.  To  my 
mind  there  are  serious  objections  to  this  teaching:  (1)  in  the  vast 
majority  of  cases  there  is  no  way  of  telling  beforehand  whether  or  not 
the  abscess  is  in  direct  contact  with  the  abdominal  wall,  and  as  a 
matter  of  fact  in  a  great  many  cases  no  such  direct  contact  exists; 
(2)  in  cutting  down  upon  the  point  where  the  abscess  is  supposed  to 
be  in  contact  with  the  abdominal  wall,  one  cannot  be  sure  that  he  will 
not  extend  his  incision  too  far  in  one  direction  or  the  other  and  so 
trespass  upon  uninfected  peritoneum  at  the  same  moment  that  he 
gives  exit  to  the  pus,  thus  running  the  grave  risk  of  spreading  infection 
within  the  peritoneum;  (3)  in  an  endeavor  to  prevent  this  error  in  tech- 
nique it  is  necessary  to  make  a  funnel-shaped  wound  in  the  abdominal 
wall — very  large  in  its  superficial  part  and  very  small  in  the  depths; 
the  surgeon  has  to  work  in  a  confined  space  at  the  bottom  of  a  deep 
wound;  often  the  appendix  cannot  be  found,  and  a  second  operation 
is  necessary  to  remove  it;  and  in  any  event  the  large  wound  (made 
fortuitously  according  to  the  site  of  the  abscess,  and  not  with  respect 
to  the  anatomy  of  the  abdominal  wall)  must  be  left  open  almost  in 
its  whole  extent,  and  post-operative  hernia  is  the  rule;  (4)  last,  but  by 
no  means  least,  in  e\acuating  an  abscess  in  this  way  the  surgeon  cannot 
be  sure  that  he  has  not  ruptured  the  abscess  wall  on  the  opposite  side — 
that  toward  the  general  peritoneal  cavity — thus  causing  leakage  of 
pus  into  uninfected  areas.  Only  when  the  abscess  is  almost  ready  to 
burst  through  the  abdominal  wall,  or  rarely  through  the  rectum,  and 
the  patient  is  gravely  ill,  am  I  in  the  habit  of  incising  directly  into  the 


GANGRENOLS   A  I'l'ES  1)1(1  TIS 


cSOl 


ahscfss  cavity.  In  such  cases,  wliich  arc  mostly  residual  abscesses, 
1  make  no  attempt  to  remove  the  aj)pcii(lix  at  the  first  operation, 
which  need  consume  only  about  five  minutes  and  may  be  done  imdcr 
local  anesthesia  or  under  nitrous  oxide. 

In  the  ordinary  cases  of  appendicular  al)scess  I  believe,  with  Mnri)hy, 
that  it  is  nnicli  safer  first  of  all  to  open  the  iiealthy  peritoneal  cavity 
on  the  median  or  ui)per  side  of  the  abscess  mass,  and  to  isolate  the 
entire  diseased  area  b}'  gauze 
packs.  Then  one  may  extend 
the  incision  to  as  great  a  length 
as  seems  desirable  (Fig.  N47) ; 
and,  after  evacuating  the  ab- 
scess at  leisure  and  with  perfect 
control  of  the  infective  material, 
may  complete  the  ojjcration  by 
removal  of  the  appendix,  and 
may  close  the  greater  part  of 
the  abdominal  wound,  leaving 
only  sufficient  space  unsutured 
for  the  emergence  of  the  drains. 
With  such  treatment  hernia  is 
a  very  rare  sequel,  and  no  sec- 
ondary operation  is  required. 

In  all  operations  for  appendic- 
ular abscess  the  surgeon  should 
make  sure  that  no  pelvic  collec- 
tion of  pus  is  overlooked.  This 
is  determined  by  passing  a  glass  tube,  along  the  fingers  as  a  guide,  to  the 
bottom  of  the  pelvis;  through  the  lumen  of  the  glass  tube  a  rubber  tube 
is  then  inserted  to  the  floor  of  the  pelvis,  and  by  means  of  a  syringe 
attached  to  its  outer  end  suction  is  exerted,  and  any  fluid  in  the  pelvis 
will  be  drawn  into  the  syringe.  If  the  abscess  occupies  the  iliac  fossa 
or  loin,  and  no  pus  is  found  in  the  pelvis  when  it  is  explored  as  just 
indicated,  it  will  be  safe  usually  to  be  content  with  drainage  extending 
only  to  the  base  of  the  appendix  and  the  site  of  the  abscess  cavity.  In 
cases  where  pus  has  been  found  in  the  pelvis,  or  in  other  cases  if  there 
is  any  uncertainty  as  to  the  efficiency  of  the  drainage,  it  is  proper  to 
drain  the  pelvis  also.  For  this  purpose  a  rubber  tube  suffices,  and  acts 
as  a  better  drain  than  does  a-wick  of  gauze.  The  drain  should  emerge 
at  the  outer  angle  of  the  transverse  incision,  or  at  the  lower  angle  of 
a  longitudinal  wound.  The  drain  should  not  be  removed  for  at  least 
four  days,  and  it  is  better  then  to  shorten  it  by  degrees.  Too  early 
removal  of  the  drainage  frequently  leads  to  the  damming  up  of  pus 
and  the  formation  of  a  residual  abscess.  Though  such  collections 
usually  can  be  opened  by  inserting  a  finger  into  the  wound,  without  a 
general  anesthetic,  sometimes  formal  operation  is  necessary. 

Gaxgrexous  Appendicitis. — Though  an  appendix  associated  with 
an  abscess  or  with  diffuse  peritonitis  frequently  is  necrotic  wholly 


Fig.  847. — \'ery  large  transverse  incision 
in  a  cas2  of  appendicular  abscess,  drained 
from  its  outer  end.  Two  months  after  opera- 
tion.    Episcopal  Hospital. 


862 


SURGERY  OF   THE  G ASTRO-INTESTINAL   TRACT 


or  in  part,  there  is  a  clinical  distinction  between  such  cases  and  those 
classed  as  gangrenous  appendicitis.  In  the  latter  class,  necrosis  of  the 
appendix  occurs  with  such  rapidity,  usually  as  the  result  of  vascular 
thrombosis,  that  no  adequate  peritoneal  reaction  develops,  and  the 
necrotic  organ  lies  free  from  limiting  adhesions  or  protecting  omentum 
in  an  almost  normal  abdomen.  Unless  such  an  appendix  is  removed 
promptly,  it  will  separate  as  a  slough  from  the  cecum  and  fecal 
extravasation  will  cause  very  severe  septic  (toxic)  peritonitis,  often 
costing  the  patient  his  life. 

There  are  no  certain  syviytoms  by  which  the  occurrence  of  gangrene 
may  be  recognized;  but  sudden  cessation  of  pain,  especially  if  extreme 
tenderness  persists,  should  make  one  suspect  the  occurrence  of  gan- 
grene. The  fact  that  gangrene  has  occurred,  thus  checking  absorption 
of  toxins,  may  also  explain  rather  abrupt  disappearance  (unfortunately 
only  temporary)  of  systemic  symptoms  of  infection. 

The  only  efficient  treatment  is  immediate  removal  of  the  appendix. 
It  is  wise  to  drain  the  wound  in  every  case. 

Diffuse  Peritonitis. — The  pathogenesis,  symptomatology,  and 
indications  for  operation  have  been  discussed  at  p.  806.     In  cases 

deemed  suitable  for  operation, 
the  surgeon  must  aim  to  make 
the  operation  as  short  as  possi- 
ble (Fig.  848).  After  opening 
the  peritoneum,  the  appendix  is 
sought,  and  if  readily  found  is 
brought  into  the  wound  and  re- 
moved. Then  a  glass  drainage 
tube  is  passed  to  the  bottom  of 
the  pelvis,  and  any  fluid  which 
has  collected  there  is  removed 
by  suction  as  described  under 
the  treatment  of  pelvic  abscess 
(p.  861).  If  the  head  of  the 
operating  table  is  raised  after 
evacuating  the  pelvis,  the  fluid 
which  lay  in  the  patient's  flanks 
will  trickle  over  the  brim  of 
the  pelvis  and  may  be  removed  thence  by  suction.  A  gauze  wick  is 
carried  down  to  the  pelvis  behind  the  glass  tube,  and  both  the  glass 
tube  and  the  gauze  wick  are  allowed  to  remain  for  drainage.  The 
patient  is  returned  to  bed  in  the  head  high  position,  and  the  usual 
treatment  for  peritonitis  (p.  811)  is  continued.  The  glass  tube  should 
be  exhausted  once  or  twice  daily,  and  at  each  dressing  should  be  rotated 
slightly  so  as  to  prevent  its  fixation  by  adhesions.  When  the  discharge 
ceases  to  be  purulent,  usually  about  the  third  or  fourth  day,  the  glass 
tube  should  be  substituted  by  one  of  rubber.  The  rubber  tube  should 
be  inserted  as  far  as  the  floor  of  the  pelvis  through  the  lumen  of  the 
glass  tube,  which  is  then  withdrawn  over  it ;  if  the  glass  tube  is  with- 


"^^ 


Fig.  848. — Small  right  rectus  incision,  in 
a  case  of  diffuse  peritonitis  from  appendicitis. 
Episcopal  Hospital. 


CHRONIC  APPENDICITIS  863 

drawn  brt'ort'  the  ruhher  tube  is  in  place,  the  drain  tract  will  collapse 
and  it  will  be  inij)()ssible  to  insert  the  rnbber  tube.  The  ^auze  wick 
is  rcnio\'e(l  from  the  fourth  to  the  tenth  day,  and  the  rubl)er  tube 
is  f:;radually  shortened,  allowinj^  the  sinus  to  heal  by  {granulation. 

K  the  appendix  is  not  removed  at  the  first  operation,  the  patient 
should  be  strongly  urj^ed  to  have  this  done  so  soon  as  convalescence 
is  coni[>lete.  The  freciuency  of  second  attacks  of  a])pendicitis  is  j^reat, 
and  they  are  attended  by  all  the  dangers  of  the  first.  Even  should 
no  such  acute  attacks  occur,  the  presence  of  the  diseased  organ  and  of 
the  adhesions  which  surround  it  often  seriously  impairs  the  patient's 
comfort  and  may  render  him  a  semi-invalid;  moreover,  the  appendix 
may  undergo  malignant  change. 

Chronic  Appendicitis. — The  pathogenesis  of  this  condition  was  dis- 
cussed at  p.  N41).  The  ftympioms  are  many  and  various.  Pain  is  the 
most  constant  symptom  and  is  one  without  which  the  diagnosis  cannot 
be  made  accurately.  In  most  cases  the  pain  is  localized  to  the  region 
affected,  but  it  may  be  referred  through  the  pull  of  adhesions  to 
various  parts  of  the  abdomen.  Gastric  dyspepsia  is  frequent,  and  may 
be  the  predominant  symptom.  The  stomach,  as  W.  J.  ^Nlayo  points 
out,  is  the  mouth-piece  of  the  gastro-intestinal  tract.  Disorders 
anywhere  in  this  tract  are  constantly  calling  attention  to  their  pres- 
ence through  disorders  of  the  stomach.  This  is  true,  of  course,  espe- 
cially of  gastric  and  duodenal  lesions;  but  it  is  equally  true  of  gall- 
stones and  of  clironic  appendicitis,  as  well  perhaps  as  of  other  less 
frequent  lesions.  The  characteristics  of  the  tlyspepsia  due  to  chronic 
appendicitis  are  sufficiently  distinct  to  enable  a  diagnosis  to  be  made 
in  most  cases.  The  gastric  symptoms  occur  with  no  regularity  as 
regards  ingestion  of  food,  nor  is  relief  obtained  by  eating.  Indeed, 
eating  usually  aggravates  the  indigestion,  but  with  no  constancy  or 
regularity.  The  patient  complains  of  general  abdominal  pain,  mostly 
below  tliQ  umbilicus.  The  patient  usually  is  about  thirty  years  of 
age.  Patients  past  thirty-fi\e  years  much  more  often  suffer  from 
dyspepsia  due  to  gall-stones,  and  those  past  forty  years  from  that 
due  to  gastric  ulcer  or  its  sequels.  Apart  from  the  symptoms  of 
chronic  appendicitis,  a  good  deal  of  reliance  should  be  placed  on  the 
history  of  the  case,  and  particularly  on  the  physical  examination. 
Usually  there  will  have  been  one  or  two  attacks  of  abdominal  pain 
or  distress  sufficiently  acute  to  have  laid  the  patient  up  for  a  day  or 
so,  even  if  not  so  acute  as  to  have  been  recognized  at  the  time  as 
attacks  of  appendicitis.  Even  when  such  a  history  is  lacking,  deep 
palpation  of  the  abdomen  over  the  right  iliac  fossa  almost  invariably 
detects  marked  localized  tenderness  even  when  none  is  complained  of 
by  the  patient. 

Treatment. — The  treatment  of  the  disease  consists  in  removal 
of  the  appendix.  Often  this  contains  a  fecal  concretion,  and  evi- 
dences may  be  found  of  past  inflammation  within  the  appendix 
(strictures,  obliteration  of  its  tip),  or  without  it  (peritoneal  adhesions, 
kinks,  etc.). 


864  SURGERY  OF   THE  GASTRO-INTESTINAL   TRACT 

Primary  Carcinoma  of  the  Appendix  is  found  in  about  1  per  cent,  of 
cases  wliicli  come  to  operation  or  necropsy.  Without  microscopical 
examination  tlie  lesion  usually  is  overlooked.  It  causes  no  symptoms 
which  suffice  to  distinguish  it  from  clironic  appendicitis,  with  which 
it  often  is  associated.  Its  frequency  is  an  argument  for  the  removal 
of  the  appendix  as  an  incident  in  the  course  of  other  abdominal 
operations. 

Tuberculosis  of  the  Appendix  is  scarcely  less  frequent  than  carci- 
noma. If  any  symptoms  are  produced  the\'  are  indistinguishable  from 
those  of  chronic  appendicitis,  except  when  the  tuberculous  infection 
has  spread  so  far  as  to  give  rise  to  the  clinical  picture  of  tuberculosis 
of  the  peritoneum  (p.  815).  The  appendix  should  be  removed  unless 
the  disease  is  so  widespread  as  to  make  this  unusually  difficult. 

Intussusception  of  the  Appendix  has  been  recorded  in  a  few  cases. 
The  symptoms  are  those  of  acute  appendicitis  and  the  treatment  is  the 
same. 

SURGERY  OF  THE  STOMACH  AND  DUODENUM. 

Gastric  and  Duodenal  Ulcer. — It  is  probable  that  these  ulcers,  as 
well  as  others  in  the  gastro-intestinal  tract,  are  toxemic  in  origin. 
In  practically  all  toxemias  there  are  gastro-intestinal  ulcers,  and  in 
practically  all  cases  of  gastro-intestinal  ulceration  there  is  present 
some  form  of  toxemia  (Dieulafoy,  Gandy,  1899).  The  toxemia  is  of 
infectious  origin,  and  the  infection  may  arise  in  a  clironically  inflamed 
appendix,  in  the  biliary  tract,  or  in  some  other  situation  which  is 
readily  overlooked.  Oral  sepsis  usually  is  present,  and  no  doubt 
has  etiological  relation;  constant  swallowing  of  pathogenic  microbes 
impairs  the  vitality  of  the  stomach,  and  its  acid  secretions  render 
it  more  vulnerable,  ^lechanical  indigestion,  from  rapid  eating 
("bolting"  unmasticated  food),   is  another  important  cause. 

The  earliest  stage  in  these  gastro-intestinal  lesions  is  ecchymosis; 
then  follow  hemorrhagic  infarct,  slough,  and  hemorrhagic  erosion; 
next  is  developed  the  "exulceratio  simplex"  of  Dieulafoy;  then  comes 
the  true  ulceration  with  hemorrhagic  borders;  and  then  the  final 
stages,  perforation,  chronic  ulcer  with  thickened  border  and  little  tendency 
to  heal,  or  a  cicatrix.  These  local  eflfects  probably  are  due  to  the 
action  of  hemorrhagins,  which  erode  the  endothelial  lining  of  the 
bloodvessels,  and  of  mucolysins,  which  destroy  the  gastric  mucosa. 
Ecchymosis,  the  first  stage,  is  produced  by  hemorrhagins  alone;  when 
mucolysins  also  act  an  erosion  is  produced,  and  in  time  a  fully 
developed  ulcer  will  be  formed,  unless  anti-bodies  are  formed  by  the 
organism  to  hold  these  cytolysins  in  check  (Hort,  1908).  These 
ulcers  are  not  formed  alone  in  the  stomach  and  duodenum  though 
they  are  most  frequent  here.  Other  similar  lesions,  not  so  apt  to 
produce  symptoms,  may  exist  in  the  jejunum  or  ileum  or  large  intes- 
tine, but  they  are  comparatively  rare.  In  the  mucous  membrane  of 
the  stomach  there  are  small  collections  of  lymphoid  tissue,  and  these 


GASTRIC  AM)   DUODICNAL    ULCER  865 

arc  in  jfrcatcst  iiuiuIht  al()ii<f  the  lesser  curNatun'  and  in  the  pre- 
pyloric rcfijion.  It  seems  not  ini])rol)al)le  (hat  inflainniation  of  these 
structures,  occurrinj;-  in  general  infections,  may  ha\-e  an  etiological 
relation  to  gastric  and  pyloric  ulcer. 

\\\  ulcer  in  the  stomach  or  duodenum,  when  once  formed,  is  diffi- 
cult to  heal,  partly  owin*:;  to  trauma  from  infj;csted  food,  and  to  want 
of  rest  due  to  constant  i)eristalsis,  hut  larj^cly  ()\vin<i;  to  chemical 
chanu'cs  in  the  gastric  secretions,  produciuj:;  Iti/prrclilorln/drKt.'^ 

Duodenal  ulcers  are  more  frequent  than  <;astric  (as  ;>  to  2),  and  of 
gastric  ulcers  those  near  the  pylorus  and  along  the  lesser  curvature  of 
the  stomach  are  much  the  most  frequent. 

At  first  "acute,"  "round,"  or  "open"  in  type,  the  ulcer  through 
long  duration  becomes  callous,  with  thickened  borders;  and  if  healing 
finally  occurs,  in  part  or  wholly,  the  resulting  cicatrix  will  distort 
the  stomach,  and  perhaj^s  cause  pyloric  stenosis. 

Acute  Gastric  Ulcer,  or  Open  Ulcer,  is  not  very  frequent  in  this  country. 
It  affects  especially  anemic  young  people,  especially  women,  from 
eighteen  to  twenty-five  years  of  age,  and  is  as  much  a  symptom  of 
their  disease  as  the  anemia  itself.  It  is  apt  to  give  rise  to  hemorrhage 
and  to  perforation.  The  ulcers  usually  are  multiple;  are  round; 
api)ear  punched  out  of  the  gastric  wall;  and  usually  are  from  0.5  to 
1  cm.  in  diameter. 

Symptoms. — The  characteristic  symptoms  are  severe  Inirning  pain 
soon  after  eating,  relieved  by  evacuation  of  the  stomach  either  through 
the  pylorus  or  by  vomiting.  The  pain  seems  to  be  due  to  the  increased 
acidity  of  the  gastric  juice  caused  by  the  process  of  digestion,  as  well 
as  to  peristaltic  movements  and  mechanical  trauma  by  the  food. 
There  is  hyperacidity  even  of  the  empty  stomach .  Antacids  thus  relieve 
the  pain.  iVn  area  of  tenderness  in  the  epigastrium  is  commonly  pres- 
ent, usually  to  the  right  of  the  median  line;  sometimes  a  similar  tender 
area  is  found  just  to  the  left,  more  rarely  the  right  of  the  last  two 
dorsal  vertebrae.  Vomiting  is  frequent,  often  being  self-induced  to 
relieve  pain.  The  vomitus  often  is  streaked  with  blood,  and  quite 
independently  of  the  ingestion  of  food  hematemesis  may  occur.  Pro- 
fuse and  prostrating  hemorrhage  usually  is  due  to  an  erosion  or  an 
exulceration;  more  moderate  bleeding,  especially  if  frequently  recur- 
rent, generally  is  due  to  the  round  open  ulcer. 

Chronic  Gastric  and  Duodenal  Ulcer;  Cicatrizing  or  Callous  Ulcer. — 
This  may  be  a  later  stage  of  the  open  ulcer  already  described,  but  it 
seems  clinically  often  to  have  been  chronic  from  its  commencement, 
whatever  its  pathological  origin.  It  is  a  much  more  frequent  disease 
in  this  country.  It  is  this  type  of  ulcer  which  is  more  often  duodenal 
than  gastric.     Mayo  has  established  the  position  of  the  pyloric  vein 

1  The  normal  acidity  of  the  gastric  juice  is  equivalent  to  0.48  per  cent,  hydro- 
chloric acid.  If  a  patient  is  reported  to  have  a  gastric  acidity  of  60,  this  signifies 
that  there  is  hyperchlorhydria.  If,  on  the  other  hand,  the  total  acidity  is  reported 
as  .30  or  20,  the  acidity  is  clearly  below  normal.  The  "free"  acid  of  the  gastric 
juice  normally  varies  between  0.1  and  0.2  per  cent. 
55 


866  SURGERY  OF   THE  G ASTRO-INTESTINAL   TRACT 

as  the  dividing  line,  and  classes  the  portion  of  the  duodenum  above 
the  bile  papilla  as  gastric  rather  than  intestinal  in  nature. 

The  ulcer,  which  usually  is  single,  has  thickened  borders,  and  is 
quite  irregular  in  outline.  Cicatrization  leads  to  contraction,  and 
jiyloric  stenosis  (p.  868)  is  the  most  frequent  result.  If  the  ulcer  is 
situated  on  the  lesser  curvature,  it  often  extends  on  both  anterior  and 
posterior  walls  of  the  stomach  (saddle  ulcer) ;  and  its  cicatrization  may 
produce  hour-glass  sfomach  (p.  871).  The  chronic  inflammatory 
changes  around  the  periphery  of  the  ulcer  are  frequent  forerunners 
of  carcinoma  of  the  stomach  (p.  873). 

Symptoms. — These  last  a  long  time  before  relief  is  sought  from 
surgery,  so  that  the  patients  usually  are  thirty-five  to  forty  years 
of  age  or  older  when  first  seen.  The  affection  is  commoner  in  men 
than  in  women.  Symptoms  of  dyspepsia  overshadow  everything 
else.  These  dyspeptic  attacks,  characterized  by  flatulence,  pain, 
palpitations  of  the  heart,  epigastric  distress,  belching,  sour  eructa- 
tions, nausea  and  even  vomiting,  occur  in  periods  which  last  several 
weeks  at  a  time.  During  the  intervals  the  patient  suffers  less,  but  is 
not  entirely  free  from  symptoms.  The  pain  and  distress  do  not  begin 
until  tliree  or  four  hours  after  meals,  and  are  relieved  by  ingestion 
of  more  food  (himger-pain  of  INIayo  Robson).  This  is  because  the 
excess  of  acid  is  neutralized  by  food.  Patients  are  unwilling  to  go 
without  food  for  more  than  a  few  hours  at  a  time.  This  constant 
and  regular  recurrence  of  gastric  dyspepsia  several  hours  after  meals 
is  particularly  characteristic.  The  dyspepsia  due  to  chronic  appendi- 
citis (p.  863)  is  both  inconstant  and  irregular  in  its  occurrence,  and 
is  not  relieved  by  eating.  In  chronic  gastric  or  duodenal  ulcer,  how- 
ever, the  distress  from  indigestion  may  finally  become  so  extreme, 
that  a  patient  will  be  unable  to  eat  his  full  meals.  He  may  be 
reduced  to  carrying  a  bottle  of  milk  around  with  him,  taking  a  sip 
every  little  while,  to  relieve  the  burning  sensation  in  his  stomach. 
Hemorrhage,  as  has  been  remarked,  is  less  usual  in  chronic  than  in 
acute  ulcer,  and  rarely  is  large  in  amount.  If  the  ulcer  is  duodenal, 
blood  in  the  stools  (melena)  is  more  frequent  than  hematemesis;  the 
bleeding  may  be  occult  or  visible  to  the  naked  eye. 

Physical  examination  is  of  much  less  assistance  at  this  stage  of  the 
disease,  than  later,  when  pyloric  obstruction  has  developed.  Tender- 
ness is  rather  diffuse;  and  occasionally  a  mass  may  be  felt  in  the 
pyloric  region,  and  may  be  mistaken  for  carcinoma. 

Prognosis  and  Treatment  of  Gastric  and  Duodenal  Ulcer. — Hemor- 
rhage kills  about  5  per  cent,  of  patients,  and  perforation  about  15  per 
cent.  Of  the  80  per  cent,  which  remain,  prompt,  efficient,  and  pro- 
longed medical  treatment  will  cure  perhaps  three-fourths;  but  this 
cure  seldom  is  permanent.  From  30  to  50  per  cent,  of  patients  so 
cured  have  relapses,  and  though  they  may  be  "cured"  a  number  of 
times  by  resort  to  medical  treatment,  the  cure  usually  is  attained  with 
greater  difficulty  and  is  less  lasting,  after  each  new  relapse.  ]\Iean- 
while  the  patient  is  subjected  to  the  danger  of  hemorrhage  and  per- 


GASTUIC   AM)    Dl'ODENAL    ULCER  <S67 

foration;  and  tlic  (l('^•('l()I)IIUMlt  of  pyloric  stenosis,  liour-glass  stomach, 
or  carcinoma  is  the  usual  termination  in  those  i)atients  who  survive. 

Medical  treatment  aims  to  encourage  healing  of  the  ulcer  largely 
hy  reducing  the  acidity  of  the  gastric  juice.  This  is  accomi)lished  by 
regulation  of  the  diet  and  the  ingestion  of  antacids.  Surgical  treat- 
ment aims  to  eiVect  a  cure  either  by  excision  of  the  diseased  structures, 
or  by  altering  the  composition  of  the  gastric  juice  more  or  less  per- 
manentl\-  1)\'  admitting  the  alkaline  duodenal  secretions  (bile  and 
pancreatic  juice)  into  the  stomach  through  a  gastro-intestinal  anasto- 
mosis. The  latter  method,  which  still  is  more  widely  emi)l()yed  than 
excision,  and  which  is  more  widely  applicable,  is  attended  by  an  opera- 
ti\e  mortalit.\'  of  o  per  cent.,  or  less,  in  the  hands  of  skilled  abdominal 
surgeons;  and  from  75  to  80  per  cent,  of  the  patients  who  recover 
are  permanently  relieved  of  symptoms  (Deaver  and  Ashhurst).  It 
is  generally  conceded,  therefore,  in  patients  whose  symptoms  recur 
after  one  or  several  "medical  cures,"  that  surgical  treatment  is  indi- 
cated; and  especially  is  this  true  of  patients  wuth  recurring  hemor- 
rhage.    Perforation  of  course  calls  for  immediate  operation. 

Operation. — If  the  stomach  is  not  bound  down  by  adhesions,  removal 
of  the  entire  ulcer-bearing  area  (Rodman,  1900),  as  in  cases  of  car- 
cinoma, is  preferred  by  many  surgeons;  this  is  especially  desirable 
when  there  is  much  inflammatory  thickening  around  the  base  of  the 
ulcer.  The  technique  of  this  operation  (partial  gastrectomy)  is 
detailed  at  p.  881.  Excision  of  an  isolated  ulcer  may  also  be  done. 
In  both  cases  a  complementary  gastrojejunostomy  is  done.  The 
mortality,  even  in  skilful  hands,  is  higher  than  that  of  simple  gastro- 
jejunostomy (p.  879),  and  I  believe  in  most  cases  the  latter 
operation  is  to  be  preferred,  unless  the  stomach  is  freely  movable  or 
unless  carcinoma  is  suspected.  If  there  is  no  pyloric  stenosis,  it  is 
well  to  plicate  the  pylorus  when  gastrojejunostomy  is  done,  since  this 
seems  to  accelerate  the  cure.  It  is  well  also  to  invert  the  ulcer  by 
a  few  sutures,  as  a  prophylactic  against  subsequent  perforation. 

Perforation  of  Gastric  or  Duodenal  Ulcer. — In  most  cases,  unless  the 
patient  is  too  ill  to  talk,  he  gives  a  history  characteristic  of  the  disease. 
Perforation  may  be  acute,  suhacide,  or  chronic.  An  acute  perforation 
is  one  which  occurs  into  the  free  peritoneal  cavity,  the  base  of  the 
ulcer  having  been  unprotected  by  adhesions.  A  subacute  perforation 
is  one  w^hich  occurs  into  such  protecting  adhesions.  A  chronic  per- 
foration occurs  into  an  adherent  viscus,  such  as  pancreas,  liver,  colon, 
gall-bladder,   etc. 

Acute  perforation  is  characterized  by  very  sudden,  extremely  severe 
epigastric  pain,  often  attended  by  shock.  The  patient  doubles  up 
with  pain,  clutching  at  his  abdomen,  and  even  after  being  got  to  bed 
may  be  found  rolling  around  in  agony,  groaning  constantly  and  secur- 
ing no  relief.  Vomiting  may  or  may  not  occur.  Collapse  is  recognized 
b}'  the  anxiety  of  countenance,  the  cold  and  clammy  surface,  the 
sudden  pallor  and  the  guarded  breathing.  The  pulse  is  feeble  but 
may  be  either  slow  or  rapid  at  first.    The  abdomen  presents  truly  a 


SG8  SURGERY  OF   THE  GASTRO-INTESTJXAL   TRACT 

"board-like"  rigidity,  and  as  a  consequence  deej)  palpation  is  valueless. 
If  the  patient  is  not  seen  soon  after  the  occurrence  of  perforation,  the 
effused  gastric  contents  may  have  travelled  down  the  right  fiank  to 
the  cecal  region,  and  the  case  may  be  mistaken  for  appendicitis. 
After  six  or  eight  hours,  the  abdomen  becomes  distended,  secondary 
vomiting  commences,  the  pulse  quickens  and  becomes  more  feeble, 
and  other  signs  of  diffuse  peritonitis  (p.  SOG)  arise. 

Treatment  consists  in  immediate  laparotomy  through  the  upper 
right  rectus,  and  suture  of  the  perforation,  which  usually  is  near  the 
pylorus.  If  suture  is  impossible,  the  perforation  should  be  tamponed 
with  gauze.  If  operation  is  done  within  a  few  hours  of  perforation 
and  especially  if  suture  stenoses  the  pylorus,  or  if  the  sutures  tear  out, 
posterior  gastro'ejunostomy  should  be  done  at  the  same  time.  In 
many  early  cases  the  abdominal  fluid  is  sterile,  particularly  if  ])er- 
f oration  occurred  in  a  fasting  stomach,  and  perhaps  because  of  the 
hyperacidity  of  the  gastric  juice;  but  in  all  cases  the  pelvis  should  be 
drained  (through  a  suprapubic  incision)  as  well  as  the  upper  a])dominal 
wound.  Subsequent  treatment  is  the  same  as  after  any  operation 
for  dift'use  peritonitis.  If  operation  is  done  within  the  first  few  hours 
of  perforation,  the  mortality  is  only  about  15  per  cent.;  if  postponed, 
the  death  rate  rises  to  33  and  to  50  per  cent. 

Suhaciite  Perforation  may  be  attended  by  the  same  type  of  symp- 
toms, though  less  severe,  as  in  acute  perforation;  or  the  condition  may 
be  found  unexpectedly  at  operation  for  the  underlying  disease.  If 
a  subacute  perforation  is  suspected  in  such  a  case,  it  is  safer  to  do 
gastrojejunostomy  without  disturbing  the  adhesions  more  than  is 
necessary.  It  may  be  Aery  difficult  to  secure  efficient  closure  of 
such  a  perforation  by  suture. 

In  chronic  perforation  no  additional  symptoms  are  produced  at  the 
actual  moment  when  the  gastric  wall  ceases  to  form  the  floor  of  the 
ulcer  and  its  place  is  taken  by  pancreatic  tissue  or  by  firm  fibrino- 
plastic  material,  so  that  the  symptoms  which  first  call  attention  to 
the  changed  condition  are  not  those  of  perforation  nor  of  peritonitis, 
but  of  sepsis  due  to  some  form  of  perigastric  or  subphrenic  abscess, 
or  to  some  internal  fistula.  Treatment  involves  drainage  of  such  an 
abscess  and  operative  cure  of  the  gastric  lesion. 

Hemorrhage  in  Gastric  and  Duodenal  Ulcers. — The  diagnosis  usually 
is  not  difficult,  but  the  diagnosis  of  gastric  ulcer  has  been  made  in 
cases  of  bleeding  from  esophageal  varices.  Treatment  during  continu- 
ance of  bleeding  should  be  purely  medical:  morphin  hypodermically, 
an  ice  bag  to  the  epigastrium,  and  nothing  whatever  by  mouth. 
Operation  at  this  time  is  too  dangerous  to  be  recommended;  the  mor- 
tality is  from  GO  to  80  per  cent.  When  the  hemorrhage  has  ceased, 
however,  and  the  patient  has  regained  some  measure  of  health,  opera- 
tion should  be  done  to  cure  the  ulcer.  Especially  important  is  this 
when  repeated  hemorrhage  occurs. 

Pyloric  Obstruction. — This  includes  three  distinct  affections: 
Infantile  Pyloric  Stenosis;  Pylorospasm;  Gastric  Dilatation. 


I'YLOh'lC   onSThTCTION  809 

Infantile  Stenosis  of  the  Pylorus.  —The  baby  usually  is  hcaltliy  at 
birth,  l)u1  within  a  week  or  so  develops  the  eoiulition  (lescrilx'd  as 
hyperemesis  lactantium.  Unless  arrested,  the  alVeetioii  projijresses 
until  j;astrie  piM-istalsis  can  be  seen  through  the  emaciated  abtloniinal 
wall,  and  a  pyloric  tumor  can  be  felt.  The  obstruction  usually  i-s 
due  to  excess  of  nuiscular  tissue  about  the  pylorus.  The  cause  of  this 
change  is  not  certain,  but  probably  is  hypertr()i)hic.  In  most  cases 
medical  treatment  brink's  relief  before  complete  obstruction  develoj)s; 
but  unless  loss  of  weight  is  checked  very  soon  operation  should  be 
done.  Posterior  gastrojejunostomy  is  the  operation  usually  employed. 
Nicoll  ( lOOC))  has  had  nuich  success  with  a  special  form  of  i)yloropliisty. 

Pylorospasm.  -  This  is  an  intermittent  or  constant  contraction  of 
the  pyloric  sphincter,  attended  by  more  or  less  evident  symptoms. 
It  is  itself  only  a  symptom  of  a  lesion  which  may  be  in  the  stomach 
or  elsewhere.  Pyloros])asm  not  infrequently  accompanies  gallstone 
colic  or  aj)pendicitis.  In  many  cases  the  pain  is  not  very  great, 
amoimting  merely  to  a  lively  sense  of  discomfort  in  the  epigastric 
region,  and  being  overshadowed  by  symptoms  of  "peristaltic  unrest 
of  the  stomach"  (Kussmaul,  1880):  w'hen  the  pylorus  contracts 
spasmodically  the  stomach  meets  with  an  insuperable  obstacle  to  its 
evacuation;  peristaltic  unrest  ensues,  flatulence  develops  from  fer- 
mentation and  from  swallow^ed  air;  and,  finally,  when  the  limit  of 
endurance  is  reached,  the  pylorus  relaxes  and  gastric  contents  pass 
out  into  the  duodenum  or  the  patient  is  relieved  of  his  distress  by 
vomiting.  Secondary  gastric  dilatation  may  ensue.  Treatment  is  that 
of  the  causative  condition. 

Gastric  Dilatation. — Acute  Dilatation  of  the  Stomach  (Hilton 
Fagge,  1872)  is  met  with  as  a  complication  in  various  infectious 
diseases,  notably  typhoid  fever  and  pneumonia;  as  well  as  after  some 
operations,  not  always  involving  the  abdomen.  Though  not  caused 
by  pyloric  obstruction,  it  seems  best  to  mention  the  condition  in  this 
place. 

The  stomach  fills  nearly  the  whole  abdomen,  and  the  site  of  apparent 
obstruction  usually  is  found  at  or  near  the  duodenojejunal  angle. 
A  physiological  fact  pointed  out  by  Kelling  (1900)  may  have  some 
bearing  on  the  condition:  this  is  that  so  long  as  the  duodenum  is 
distended  the  stomach  is  unable  to  empty  itself.  Many  surgeons  still 
support  the  theory  of  Hanau-Albrecht  (1899),  that  acute  dilatation 
of  the  stomach  is  caused  by  constriction  of  the  transverse  duodenum 
by  the  superior  mesenteric  artery,  from  the  drag  of  the  small  intestines 
(gastro-mesenteric  ileus). 

Vomiting  is  profuse  and  repeated,  and  there  is  little  nausea;  immense 
cjuantities  of  fluid  are  brought  up  in  this  w^ay,  demonstrating  hyper- 
secretion by  the  stomach.  Gaseous  distention  is  extreme,  and  the 
outlines  of  the  stomach  may  be  recognized  tlirough  the  abdominal 
wall.  When  the  stomach  tube  is  passed  there  is  an  abundant  escape 
of  odorless  gas,  with  a  gushing  or  gurgling  sound,  at  times  almost  an 
explosion.    Marked  flattening  of  the  abdomen  follows  this  evacuation, 


870  SURGERY  OF   THE  GASTRO-INTESTINAL   TRACT 

but  soon  the  stomach  refills  with  fluid  and  air.  Signs  of  collapse, 
largely  due  to  deprivation  of  the  tissues  of  so  much  liquid,  quickly 
follow.  Occasionally  spontaneous  relief  occurs,  and  profuse  diarrhea 
ushers   in  convalescence. 

Treatment. — Treatment  consists  in  repeated  use  of  the  stomach 
tube;  and  in  placing  the  patient  prone  or  on  the  left  side,  with  the  foot 
of  the  bed  elevated,  with  a  view  to  overcoming  an  obstruction  at  the 
duodenojejunal  angle.  Or  the  patient  may  assume  the  knee-chest 
posture.  Operation  to  relieve  a  kink,  or  to  perform  gastrojejunostomy 
should  be  the  last  resort. 

Secoxdary  Gastric  Dilatation. — This  is  not  a  distinct  disease, 
but  is  the  terminal  stage  of  some  preexisting  disease  which  causes 
pyloric  obstruction.  The  most  frequent  causes  are  carcinoma,  chronic 
gastric  or  duodenal  ulcer,  or  perigastric  adhesions  usually  due  to 
disease  of  the  biliary  tract.  Benign  pyloric  obstruction  usually  is 
due  to  contraction  of  ulcers  near  the  pylorus.  Occasionally  in  the 
earlier  stages  of  ulceration  such  hyperplastic  reaction  occurs  as  to 
cause  temporary  obstruction  of  the  pylorus;  if  gastrojejunostomy 
is  done  at  this  stage  the  pylorus  may  subsequently  become  patulous, 
just  as  it  might  have  done  if  no  operation  had  been  employed.  But 
when  cicatricial  stenosis  once  develops  the  prognosis  is  hopeless  with- 
out operation. 

Symptoms. — Tlu"ee  stages  are  recognized :  In  the  stage  of  compensa- 
tion it  is  only  after  an  unusually  heavy  meal  that  distress  is  experi- 
enced; gaseous  distention  becomes  oppressive,  the  clothing  is  perhaps 
unconsciously  loosened,  and  relief  eventually  is  obtained  by  the 
belching  of  gas  and  the  eructation  of  a  little  sour  fluid.  Finally  the 
wearied  stomach  empties  itself  into  the  duodenum.  This  stage  may 
last  for  months  or  years,  but  eventually  the  .stage  of  stagnation  is 
developed:  here  the  stomach  is  unable  completely  to  evacuate  its 
contents  between  meals,  except  in  the  long  interval  at  night.  A  sense 
of  fulness  persists  from  one  meal  to  the  next,  and  anorexia  develops. 
Weight  may  not  be  lost,  but  none  is  gained.  In  the  stage  of  retention 
emaciation  commences  and  may  become  extreme.  The  stomach 
is  not  emptied  e\en  during  the  night;  lavage  before  breakfast  will 
detect  food  particles  still  in  the  stomach,  and  the  gastric  contents 
will  be  sour,  rancid,  and  usually  very  acid.  The  evidences  of  fermenta- 
tion are  pronounced,  and  production  of  gas  may  continue  after  the 
stomach  contents  have  been  removed,  as  is  evidenced  by  their  separa- 
tion into  three  typical  layers  on  standing.  Because  fluids  are  not 
absorbed  from  the  stomach,  and  because  in  this  stage  they  are  late 
in  reaching  the  small  intestine,  if  they  reach  it  at  all,  there  is  more 
or  less  constant  thirst.  As  retention  becomes  extreme,  the  stomach 
occasionally  makes  an  attempt  to  empty  itself  by  the  act  of  vomiting; 
though  generally  incomplete  evacuation  is  secured,  temporary  relief 
is  obtained.  Copious  and  cumulative  vomiting  which  occurs  every 
few  days  is  very  good  evidence  that  the  stomach  is  dilated.  Occa- 
sionallv  tetanv  occurs. 


HOUR-GLASS  STOMACH  871 

Physical  IShjtus.  Tlic  capacity  of  the  stuiiiacli  is  seen  to  be  increased 
not  only  from  the  large  amount  of  the  vomitus,  but  by  lavage.  Skiag- 
raphy at  various  intervals  after  the  ingestion  of  bismuth  gruel  will 
demonstrate  the  gastric  retention,  and  dilatation.  The  greater 
curvature  almost  always  is  below  the  uml)ilicus  and  may  reach  to  the 
peKis.  Tiie  stomach  may  be  cautiously  distended  with  air  by  a  hand 
bulb  attached  to  the  stomach  tube.  The  outlines  can  then  be  deter- 
mined by  i)ercussion.  Analysis  of  the  feces  shows  the  solid  matter 
reduced  to  less  than  half  the  Jiormal  of  4  to  0  oz.  in  twenty-four  hours; 
while  the  proportion  of  water  falls  as  low  as  40  or  even  30  i)er  cent, 
of  normal.    The  urine  also  is  diminished  in  quantity. 

Diagnosis. — The  diagnosis  is  based  on  a  history  indicative  of  a 
previous  disease  which  might  cause  pyloric  obstruction,  and  upon  the 
existence  of  the  symptoms  and  physical  signs  mentioned  above. 
In  gasiroptosis ,  though  the  stomach  may  be  dilated,  there  is  no  clinical 
history  characteristic  of  gastric  ulcer  or  gall-stones. 

Prognosis  and  Treatment. — This  is  the  terminal  stage  of  a  serious 
disease.  Gastric  dilatation  due  to  benign  obstruction  is  less  serious 
than  gastric  carcinoma  only  because  patients  with  the  former  disease 
die  more  slowly  than  do  those  with  cancer.  Cancer  usually  kills  in  a 
shorter  time,  but  death  in  benign  dilatation  is  quite  as  sure  even  if 
longer  delayed.  The  starvation  is  slow,  and  it  is  barely  possible  that 
the  patient  will  not  recognize  the  fact  that  he  is  starving  to  death; 
yet  he  should  be  told  that  surgery  affords  the  only  escape  from  death. 
A  measure  of  comfort  may  be  secured,  in  the  earlier  stages,  by  periodic 
gastric  lavage  and  careful  regulation  of  diet;  but  no  true  improvement 
takes  place.  What  the  surgeon  urges  is  that  operation  shall  be  under- 
taken while  yet  there  is  sufficient  recuperative  power  left  in  the  body 
cells  of  the  wretched  patient.  The  choice  of  operation  lies  between 
gastrojejunostomy,  which  is  preferable  in  most  cases;  partial  gas- 
trectomy, which  is  indicated  if  malignancy  is  suspected;  and  some  form 
of  pyloroplasty,  which  is  not  to  be  recommended  except  in  patients 
whose  gastric  motility  is  only  slightly  impaired. 

Hour-glass  Stomach. — As  more  than  two  pouches  may  exist,  the 
term  segmented  stomach  (Wolfler,  1895)  is  preferable,  though  little 
used.  The  deformity  usually  is  the  result  of  contraction  of  an  ulcer, 
but  perigastric  adhesions  may  be  the  cause,  or  even  carcinoma  (Fig. 
849).  The  pouches  may  be  of  various  sizes,  or  diverticula  may  exist.. 
The  sijmptoms  seldom  can  be  distinguished  from  those  of  pyloric 
obstruction,  which  often  is  present  as  an  additional  complication; 
and  the  diagnosis  depends  chiefly  on  the  use  of  the  stomach  tube, 
and  filling  the  stomach  with  air  or  water,  by  means  of  which  the  exist- 
ence of  more  than  one  compartment  may  be  detected  m  many  cases. 
Often  where  no  such  abnormality  exists,  a  skiagraph  wdll  show  wdiat  is 
apparently  an  hour-glass  constriction.  Treatment  consists  in  some 
form  of  operation  to  overcome  the  obstruction.  In  gastroplasty  (Fig. 
850)  an  incision  is  made  through  the  constriction  in  the  long  axis  of 
the  stomach  and  is  sutured  transversely;  the  operation  is  analogous 


872 


SURGERY  OF   THE  GASTRO-INTESTINAL   TRACT 


to  pyloroplasty  (p.  878).     In  gasirogasirostomy  (Fig.  851)   a  lateral 
anastomosis  is  made  between  the  adjacent  pouches.     Gastro-una.sto- 


FiG.  849. — Hour-glass  stomach  from  carcinomatous  "saddle "  ulcer  on  lesser  curvature, 
with  perforation;  death  from  peritonitis  (half  natural  size).  (Deaver  and  Ashhurst.) 
Episcopal  Hosjiital. 


Fig.  850. — Gastroplasty.      (Deaver  and 
Ashhurst.) 


Fig.  851. — Gastro-gastrostoniy. 
and  Ashhurst.) 


(Deaver 


mosis  (Fig.  852)  is  analogous  to  Finney's  pyloroplasty  (p.  879).  In 
the  majority  of  cases  gusirojcjnnostomy  in  the  cardiac  pouch  is  to  be  pre- 
ferred to  the  operations  just  men- 
tioned. As  the  cardiac  pouch  may 
be  so  small  as  to  pass  unperceived, 
the  entire  stomach  should  be  ex- 
amined before  any  operation  is  done. 
If  pyloric  stenosis  also  is  present,  it 
may  be  necessary  todo  pyloroplasty 
in  addition,  or  even  to  make  a 
second  anastomosis,  between  the 
jejunum  and  the  pyloric  pouch. 
^    ,  ,        •     .T^  Plastic  Linitis  {Cirrhosis  of  the 

-Ciastro-anastomosis.    (Deaver       o,  i     r,      i  i  / 

and  Ashhurst.)  Moiuach,  Zuckerqiissmaqcu ,  Maqen- 


FiG.  852. 


CAh'CLXOMA    OF    TUh'  STOMACH  S7.S 

sclirutiipfiuuj,  etc.)  -This  is  a  diU'iist'  sclerosis  of  tlu'  stoiiiacli,  especially 
of  the  subnuieous  tissues,  leading  to  marked  thickening  of  the  gastric 
walls  and  diminution  in  the  cajjacity  of  the  stomach.  It  may  be 
benign  or  malignant  in  nature,  and  probably  may  arise  in  several 
difi'erent  diseases,  such  as  carcinoma,  syphilis,  polyserositis,  lymphatic 
obstruction,  etc.  Thomson  and  Graham  (191.'^)  have  reviewed  the 
subject  at  some  length,  and  j^refer  to  term  the  condition  a  "fil)roma- 
tosis."  If  the  change  is  recognized  early  enough,  j)artial  gastrectomy 
may  be  attempted;  as  a  palliati\e  measure  gastro-enterostomy  may 
be  (lone,  or  even  duodenostomy  or  jejunostomy. 

Gastroptosis.     See  Vis(er()ptosis,  p.  S9S. 

Carcinoma  of  the  Stomach.  This  is  a  very  frequent  disease,  l)ut  it 
seldom  is  recognized  in  time  to  save  the  patient's  life.  About  75 
per  cent,  of  cases  of  gastric  carcinoma  can  be  shown  by  microscopic 
study  to  have  had  their  origin  in  chronic  ulcer  of  the  stomach.  This 
is  an  unansweral)le  argument  in  favor  of  prompt  and  lasting  cure  of 
such  ulcers  by  surgical  means.  This  class  of  patients  with  incipient 
gastric  cancer  has  been  recognized  only  recently.  Hitherto  they  have 
been  treated  for  chronic  gastritis,  dyspepsia,  etc.,  and  it  was  not  until 
frequent  surgical  intervention  became  the  rule  in  such  cases  that  it 
was  })roved  that  tlie  change  from  the  benign  to  the  malignant  state 
manifests  itself  by  no  clinical  symptoms. 

Cancer  of  the  stomach  presents  clinically  two  forms.  In  one  a 
patient  past  middle  life,  without  having  suffered  previoush'  from  indi- 
gestion, suddenly  loses  appetite,  especially  for  meats,  grows  pro- 
gressively weaker  and  more  emaciated,  develops  epigastric  pain  and 
possibly  a  palpable  mass,  becomes  subject  to  vomiting  spells  every 
few  days,  which  bring  up  a  quantity  of  coffee-ground  material,  foul 
smelling  and  fermented;  and  quickly  develops  the  cancerous  cachexia. 
This  is  the  classical  picture  of  gastric  carcinoma,  and  it  is  still  seen; 
but  it  is  very  rare  when  compared  with  that  other  course  of  develop- 
ment which  I  have  just  mentioned.  Gastric  carcinoma  appears  with 
sudden  onset  in  not  more  than  10  per  cent,  of  cases.  The  second  and 
much  more  frequent  course  is  found  in  patients  who  have  been  long 
sufferers  from  dyspepsia.  Medical  treatment  has  given  relief  at  times, 
but  indigestion  recurs  again  and  again.  Appetite  may  be  preserved, 
but  digestion  is  torture;  so  abstemiousness  becomes  the  rule.  There 
may  or  there  may  not  ha^•e  been  some  period  when  gastric  ulcer  was 
suspected  or  actually  diagnosticated.  Usually  there  have  been  no 
very  definite  sj'mptoms.  Finally  these  patients  die;  and  at  autopsy 
a  wide-spreading  carcinomatous  ulcer  is  found. 

Pathology. — Carcinoma  of  the  stomach  occurs  oftenest  between  the 
ages  of  forty  and  seventy  years,  and  affects  the  sexes  about  equally. 
The  gro\rth  occurs  at  the  pylorus  in  about  60  per  cent.,  and  at  the  lesser 
curvature  in  about  10  per  cent,  of  cases.  Carcinoma  of  the  body  or 
fundus  is  rare. 

Histologically  three  types  of  gastric  cancer  are  recognized :  (1) 
Spheroidal-celled  carcinoma,  composed  of  cells  like  those  normally 


874  SURGERY  OF   THE  GASTRO-INTESTINAL   TRACT 

lining  the  gastric  tubules;  (2)  Cylindrical-celled  or  adeno-carcinoma, 
composed  of  cells  similar  to  those  normally  lining  the  gastric  glands; 
and  (3)  Colloid  carcinoma,  a  tumor  whose  chief  characteristic  is 
myxomatous  degeneration  of  epithelial  cells  and  stroma,  which  may 
occur  either  in  the  spheroidal-celled  or  cylindrical-celled  varieties. 
Clinically  carcinoma  may  be  classed  as  scirrhous  or  medullary. 

Lymphatic  extension  occurs  early.  The  main  paths  in\'aded  are 
indicated  in  Fig.  853.  Our  knowledge  of  these  lymphatics  is  due 
almost  entirely  to  Cuneo  (1900),  and  to  Jamieson  and  Dobson  (1907). 
Carcinoma,  beginning  as  it  usually  does  along  the  lesser  curvature  close 
to  the  pylorus,  invades  first  the  lymphatics  along  the  lesser  curvature, 
even  up  to  the  coronary  artery  close  to  the  cardiac  orifice  of  the 
stomach.    Hence  it  is  evident  that  ever}'  radical  operation  for  gastric 


Fig.  853. — Paths  of  lymphatic  extension  in  carcinoma  of  the  stomach.     After 
Jamieson  and  Dobson. 

cancer  must  remove  the  entire  lesser  curvature  of  the  stomach.  More- 
over, so  soon  as  the  carcinoma  is  at  all  extensive,  the  lymph  nodes  in 
the  gastro-colic  omentum,  for  a  variable  distance  away  from  the 
pylorus,  are  involved.  Therefore  Hartmanns  line  for  gastrectomy 
(i901)  was  made  to  pass  from  the  coronary  artery  to  a  point  directly 
below  it  on  the  greater  curvature  (Fig.  860).  A  third  point  of  the 
greatest  importance  is  that  whereas  the  carcinomatous, invasion  extends 
rapidly  and  for  an  indefinite  distance  away  from  the  pyloric  region 
of  the  stomach,  it  invades  the  duodenum  only  rarely.  The  removal 
of  the  first  inch  (2.5  cm.)  of  the  duodenum  nearly  invariably  enables 
the  surgeon  to  get  beyond  the  limits  of  the  growth.  Palpable  indura- 
tion stops  with  the  area  of  mucosa  involved,  but  in  the  submucosa  the 
invasion  will  have  advanced  considerably  further.  The  resection  must 
extend  from  5  to  8  cm.  away  from  the  macroscopical  tumor  on  the 
cardiac  side  of  the  growth,  and  from  1.5  to  2  cm.  from  it  on  the 


CARCINOMA    OF   THE  STOMACH  S?;') 

intrstinal  side.  Early  lyiiii:)hatic  extension,  accortlinji;  to  Janiieson  and 
Dohson,  also  occurs  along  the  inloric  and  hepatic  arteries  to  the 
sui)raj)ancreatic  lymph  nodes. 

Apart  from  the  lymph  nodes,  gastric  carcinoma  extends  oftenest  to 
the  liver,  which  is  affected  in  one-third  of  the  cases  examined  at 
autopsy.  This  invasion  occurs  along  the  radicles  of  the  portal  vein. 
In  scirrhous  carcinoma,  and  in  all  forms  which  cause  marked  ])yl()ric 
stenosis,  invasion  of  the  liver  is  long  delayed.  Invasion  of  the  great 
omentum  may  be  followed  by  grafting  of  cancer  cells  on  the  pelvic 
organs.  Invasion  of  the  left  supraclavicular  lymph  nodes,  by  permea- 
tion along  the  thoracic  duct,  is  a  very  late  sign. 

Symptoms. — ^Early  diagnosis  from  symptoms  alone  is  so  difficult  as 
to  be  usually  impossible.  Almost  always,  by  the  time  classical 
symptoms  have  developed,  the  disease  has  passed  beyond  the  stage 
curable  by  excision,  which  is  the  only  means  of  cure  at  present  known. 

Pain,  vomiting,  and  tumor;  loss  of  weight,  anemia,  and  changes  in 
the  gastric  secretion  are  the  classical  symptoms.  But  their  develop- 
ment is  so  late  that  they  do  not  bring  the  patient  to  the  surgeon  in 
a  curable  stage. 

Carcinoma  should  he  suspected  when  chronic  gastric  catarrh  exists 
without  any  discoverable  cause  (such  as  abuse  of  food,  of  alcohol, 
or  of  drugs ;  circulatory  disturbances  of  the  heart  or  liver ;  or  diseases 
such  as  cholelithiasis,  gastric  ulcer,  etc.,  which  cause  definite  lesions 
in  the  region  of  the  stomach) ;  especially  if  the  chronic  gastritis  is  in  a 
patient  over  forty  years  of  age,  and  if  it  is  attended  by  loss  of  appetite 
for  meats.  If  a  tumor  exists,  the  diagnosis  is  less  difficult;  but  the  tumor 
must  be  distinguished  from  a  distended  gall-bladder,  from  a  growth 
of  the  colon,  pancreas,  etc.  In  obscure  cases  distention  of  the  stomach 
with  air  should  not  be  neglected;  this  may  render  a  hidden  tumor  pal- 
pable, and  the  characteristic  shape  of  a  pyloric  growth  (apex  toward 
the  duodenum  and  indistinct  base  toward  the  body  of  the  stomach) 
frequently  can  be  recognized  (Kocher).  Occult  blood  in  the  stomach 
contents  and  feces  is  the  most  valuable  of  the  laboratory  findings. 
In  non-malignant  ulcerations  of  the  stomach,  rest  in  bed  with  milk 
diet  will  cause  the  disappearance  of  occult  blood.  In  cancer  no  treat- 
ment has  any  efi'ect  (Deaver  and  Ashhurst). 

Diagnosis. — The  diagnosis  can  be  only  surmised  in  most  cases  still 
in  the  operable  stage;  only  v/hen  the  abdomen  has  been  opened  (and 
not  always  then)  can  the  surgeon  be  sure  carcinoma  is  present.  If 
a  distinct  tumor  is  present,  it  generally  can  be  recognized  as  carcino- 
matous by  its  irregular  shape,  its  "  knotty"  feel,  and  by  diffused  indura- 
tion into  surrounding  structures. 

Treatment. — Whenever  there  is  evidence  of  an  anatomical  lesion 
in  the  stomach  which  is  not  relieved  by  a  few  weeks  of  judicious 
medical  treatment,  exploratory  operation  should  be  undertaken  even 
though  an  exact  pathological  diagnosis  of  the  lesion  has  not  been 
reached.  Partial  gastrectomy  (p.  881)  should  be  done  even  on  sus- 
picion of  malignancy.     The  immediate  mortality  of  this  operation  is 


876  SURGERY  OF   THE  GASTRO-INTESTINAL   TRACT 

about  25  per  cent,  in  the  hands  of  the  average  surgeon;  even  in  the 
hands  of  Robson,  Mayo,  Deaver,  and  other  skilled  abdominal  surgeons 
the  mortality  is  from  5  to  10  per  cent.  The  remote  results  indicate 
that  from  10  to  20  per  cent,  of  patients  with  carcinoma  of  the  stomach 
who  survive  radical  operation  are  cured  of  the  disease,  passing  the  three 
and  five  year  limits  without  recurrence.  This  is  a  creditable  showing 
considering  that  no  other  form  of  treatment  offers  even  the  shadow  of 
a  chance  for  cure.  Moreover,  even  if  the  patient  ultimately  dies  from 
recurrence  or  internal  metastasis,  his  life  is  prolonged  on  the  a^'erage 
for  eighteen  months  and  most  of  this  time  is  passed  in  comparative 
comfort,  and  death  finally  comes  in  less  hideous  form:  the  patient 
dies  not  of  starvation  but  of  cancerous  cachexia.  Even  when  removal 
of  the  entire  disease  by  operation  seems  impossible,  many  abdominal 
surgeons  think  that  life  is  prolonged  and  comfort  promoted  by  removal 
of  the  foul  sloughing  mass,  discharging  into  the  stomach.  It  is  w^ell 
recognized  that  gastro-enterostomy  is  not  a  good  operation  for  such 
cases;  the  immediate  mortality  is  very  high  (15  to  25  per  cent.),  and 
if  the  immediately  fatal  cases  are  included,  the  reckoning  shows 
survival  is  shorter  than  if  no  operation  had  been  employed,  while  the 
patients  who  survive  suffer  more  than  before  the  operation  and  may 
live  a  longer  time  than  if  the  abdomen  had  been  closed  without  doing 
gastro-enterostomy.  Other  palliative  operations  have  been  employed : 
in  carcinoma  of  the  cardiac  orifice  gastrostomy  has  been  done,  but  I 
believe  it  is  contraindicated  so  long  as  the  patient  can  swallow  fluids. 
Jejunostomy  and  even  duodenostomy  (above  the  bile  papilla)  may  be 
employed  as  euthanasial  measures  in  cases  where  the  body  of  the 
stomach  is  widely  infiltrated  and  the  patient  is  starving.  In  employ- 
ing such  operations  the  precarious  state  of  the  patient  must  be  remem- 
bered; the  surgeon  should  know  before  beginning  the  operation  just 
what  he  intends  to  do,  and  then  should  do  it  without  any  unnecessary 
intra-abdominal  exploration. 


OPERATIONS  ON  THE  STOMACH. 

Gastrotomy. — The  operation  of  opening  the  stomach  may  be 
required  for  the  removal  of  foreign  bodies  within  the  stomach  or 
impacted  in  the  lower  end  of  the  esophagus;  or  for  purposes  of  explora- 
tion. The  abdominal  incision  is  made  through  the  upper  left  rectus 
muscle,  close  to  the  median  line.  The  stomach  is  located  by  finding 
first  the  left  lobe  of  the  liver  and  tracing  the  gastro-hepatic  omentum 
down  to  the  lesser  curvature  of  the  stomach.  If  a  foreign  body  is  to 
be  removed,  it  should  be  located  if  possible  before  opening  the  stomach. 
After  isolating  the  stomach  with  gauze  packs,  hold  the  foreign  body 
against  the  anterior  wall  of  the  stomach  and  cut  directly  down  upon  it, 
making  the  incision  just  long  enough  to  remove  the  foreign  body. 
Then  repair  the  gastric  incision  with  at  least  two  rows  of  sutures 
(p.  <S,30),  and  close  the  abdominal  incision  without  drainage. 


OI'Kh'ATIONS  OX   TIIE  STOMACH 


877 


Gastrostomy.  Tlir  cstahlislimeiit  of  a  gastric:  fistula,  for  the  purpose 
of  iutroduciuj;-  food,  is  recpiircd  most  often  in  cases  of  imperiueal)le 
stricture  of  tlic  csoplia<;us  (p.  (195).  The  fistula  should  he  made  in  the 
pyloric  antrum,  and  not  in  the  fundus  of  the  stomach.  Several 
methods  of  operating  are  in  common  use. 

1.  Stamius  (1S94)  or  E.  J.  Scnns  (1890)  Metlml. —The  anterior 
gastric  wall  is  drawn  into  the  wound,  and  a  small  incision  is  made, 
just  large  enough  to  admit  the  end  of  a  good-sized  catheter  (No.  2(3 
French).  The  catheter  (its  outer  end  clamped)  is  inserted  for  about 
2  or  'A  cm.  inside  the  cavity  of  the  stomach,  and  is  fixed  to  the  ga.stric 
wall    by  a  single   catgut    suture. 

Then  a  purse-string  suture  of  linen 
is  taken  in  the  stomach  wall,  cir- 
cularly around  the  catheter  and 
about  2  cm.  distant  from  it;  as 
this  suture  is  tightened  the  cath- 
eter is  pushed  toward  the  cavity 
of  the  stomach  and  carries  with 
it  the  gastric  wall,  which  is  thus 
inverted  so  that  the  catheter  lies 
in  a  serous  channel  (Fig.  854). 
Two  other  purse-string  sutures 
are  similarly  passed,  and  as  each 
is  tightened  the  inverted  cone 
of  gastric  wall  is  lengthened,  so 
that  finally  the  catheter  lies  in  a 
channel    over  5    cm.  in    length. 

The  stomach  is  then  sutured  to  the  parietal  peritoneum  on  both  sides 
of  the  abdominal  wound,  and  this  is  closed  around  the  catheter. 

2.  Kaders  method  (189G)  is  the  same  as  Senn's  except  that  the 
puckering  sutures  to  invert  the  gastric  wall  around  the  tube  are  not 
passed  as  purse-strings,  but  as  parallel  sutures,  one  on  each  side  of 
the  tube. 

3.  In  WitzeVs  method  (1891)  the  tube  is  buried  in  an  oblique  manner 
in  the  gastric  wall,  by  means  of  Lembert  sutures.  After  these  sutures 
are  all  tied,  an  opening  is  made  in  the  gastric  wall  just  large  enough 
to  admit  the  end  of  the  tube;  and  after  this  has  been  introduced  and 
fixed  to  the  wall  of  the  stomach  with  one  catgut  stitch,  its  point  of 
entrance  is  covered  by  a  few  additional  Lembert  sutures  of  linen. 

The  channel  formed  from  the  cavity  of  the  stomach  to  the  skin  in 
all  these  operations  is  absolutely  continent  so  long  as  the  catheter  is 
in  place;  when  it  is  removed  leakage  may  occur,  but  if  the  catheter 
is  left  out  for  a  long  time  the  channel  tends  to  close  spontaneously, 
owing  to  the  adhesion  of  its  serous  surfaces.  Liquids  may  be  intro- 
duced into  the  stomach  through  the  tube  at  once  if  the  patient  is  much 
emaciated.  During  the  intervals  between  feedings  the  tube  should  be 
clamped,  and  it  should  be  withdrawn  for  cleaning  at  least  once  daily 
after  the  first  few"  da  vs. 


Fig.  854. — Gastrostomy  by  Stamm's 
method. 


878 


SURGERY  OF   THE  GASTRO-INTESTINAL   TRACT 


Jejunostomy  (p.  876)  sometimes  is  employed  as  a  substitute  for 
gastrostomy.  Karewski  (1896)  adopted  the  technique  employed  by 
Witzel  for  gastrostomy,  while  Mavdl  (1898)  employed  a  Y-anastomosis 

(p.  8sn. 


Fig.  855. — Incision  for  pyloroplasty.     (See  Fig.  856.) 


Fig.  856. — Pyloroplasty,  the  incision  through  the  pylorus  ready  for  suturing. 


Fig.  857. — Finney's  method  of  pyloroplasty. 

Pyloroplasty. — The   operation   for   pyloric   stenosis   devised    inde- 
pendently by  Heinecke  and  jMikulicz  is  seldom  employed  at  present. 


OPERATIONS  ON   THE  STOMACH 


879 


It  consists  in  incisin*;-  the  pylorus  in  its  long  axis  and  th(Mi  suturing 
this  incision  transversely  (Figs.  S55  and  Sf)!)).  The  incision  should 
extend  from  the  stomach  clear  through  the  pylorus  into  the  duodemmi. 
The  oi)eration  is  inefficient  in  preventing  recurrence  of  stenosis,  and 
is  un<lcsiral)le  because  it  is  necessary  to  work  in  diseased  tissues. 
The  latt(M-  objection  ai)i)lies  also  to  Finney's  pyloroplasty  (1002)  which 
is  more  efficient,  however,  because  it  approaches  the  type  of  a  lateral 
anastomosis  between  stomach  and  duodenum  (Fig.  S57). 

Gastrojejunostomy. — An  anastomosis  between  the  stomach  and 
small  intestine  was  first  done  in  1<S81  by  Wolfler  at  the  suggestion  of 
his  assistant  Nicoladoni.  The 
jejunum  was  anastomosed  with 
the  anterior  wall  of  the  stomach, 
for  malignant  obstruction  of  the 
pylorus.  In  1885  von  Hacker 
adopted  a  method  of  posterior 
gastrojejunostomy,  by  anasto- 
mosing a  loop  of  the  upper  je- 
junum with  the  posterior  gastric 
wall  through  an  opening  made 
in  the  transverse  meso-colon. 
Most  surgeons  have  now  adopted 
posterior  gastrojejunostomy  as 
the  method  of  choice,  and  use  a 
jejunal  loop  as  short  as  possible, 
as  advised  in  1901  by  Petersen, 
the  assistant  of  Czerny  (Fig. 
858). 

The  indications  for  gastrojeju- 
nostomy have  already  been  con- 
sidered. 

The  abdominal  incision  is  made 
through  the  upper  right  or  left 
rectus  muscle  close  to  the  linea 
alba.  After  careful  exploration, 
the  great  omentum  and  attached 
transverse  colon  are  drawn  out  of 
the  wound  and  pulled  upward  to 
the  patient's  right,  thus  putting 
transverse  meso-colon  on  the 
stretch,  and  bringing  the  origin 
of  the  jejunum  into  sight. 
The  transverse  meso-colon  is 
next  torn  tlirough  in  a  bloodless  area,  by  means  of  dissecting 
forceps,  and  the  opening  is  enlarged  by  the  fingers  in  an  antero- 
posterior direction  until  it  is  from  8  to  10  cm.  in  length.  The  pos- 
terior gastric  wall  is  thus  exposed  and  is  made  to  protrude  through 
the  meso-colon,  whereupon  it  is  grasped  in  an  anastomosis  forceps 


Fig.  858. — Posterior  retrocolic  gastro- 
jejunostomy. Note  the  absence  of  a  loop 
between  the  origin  of  the  jejunum  and  the 
site  of  anastomosis  and  the  slight  distortion 
of  the  organs  when  the  operation  is  com- 
pleted. 


880  SURCERY  OF   THE  GASTRO-1 XTESTI \AL   TRACT 

with  nibVjer  covered  blades.  At  least  7.5  cm.  of  the  gastric  wall 
should  be  grasped  in  this  way.  The  portion  grasped  should  be  in  the 
pyloric  antrum,  and  the  forceps  should  l)e  applied  more  or  less  trans- 
versely to  the  long  axis  of  the  stomach.  The  jejunum,  just  below 
the  duodenojejunal  juncture,  is  now  brought  forward,  anfl  a  similar 
fold  of  it  is  grasped  in  the  other  portion  of  the  anastomosis  forceps. 
The  jejunal  loop  should  be  applied  to  the  stomach  in  such  a  way  that 
its  aboral  end  is  next  the  greater  curvature  of  the  stomach,  and  its 
oral  end  next  the  lesser  curvature.  ]Moynihan  prefers  to  have  the 
jejunum  slant  toward  the  patient's  right;  while  ^layo  turns  it  toward 
the  left.  The  gastric  wall  and  jejunum  being  thus  apposed,  a  typical 
lateral  anastomosis  (p.  834)  is  made  between  them  with  needle  and 
tliread.  The  clamps  are  then  released,  and  the  edges  of  the  opening 
which  was  made  in  the  transverse  meso-colon  are  carefully  sutured  to 
the  gastric  wall  just  above  the  anastomosis  by  three  or  four  interrupted 
sero-serous  sutures.  If  this  is  neglected,  a  hernia  of  the  small  intestine 
may  occur  alongside  the  anastomosis,  into  the  lesser  peritoneal  cavity. 
The  abdominal  contents  are  then  replaced  in  proper  position,  and  the 
abdominal  wound  closed  without  drainage.  Liquids  may  be  given 
in  small  amounts  in  twelve  hours,  but  even  semi-solid  food  should 
be  withheld  for  a  week  or  ten  days. 

Anterior  Gastrojejunostomy  may  be  required  when  the  posterior 
wall  of  the  stomach  prcnes  inaccessible  on  account  of  adhesions,  etc. 
A  loop  of  jejunum  about  35  cm.  fl4  inches)  long  must  be  used,  so  as 
not  to  constrict  the  transverse  colon.  If  the  operation  must  be  com- 
pleted with  great  speed,  a  Murphy  button  may  be  employed  for  the 
anastomosis. 

Posterior  Gastrojejunostomy  in  Y. — This,  which  was  adopted  in  1897 
by  Roux  of  Lausanne,  presents  advantages  in  some  ca.ses:  the  jejunum 
is  divided  transversely  about  35  cm.  below  its  origin,  and  its  aboral 
segment  is  implanted  into  the  posterior  wall  of  the  stomach  tlirough  an 
opening  in  the  transverse  meso-colon.  Then  the  oral  segment  of  the 
jejunum  is  implanted  into  the  aboral  segment  about  15  cm.  below  the 
gastro-jejunal  anastomosis  (Fig.  859).  In  this  way  there  is  no  chance 
for  the  duodenal  secretions  to  reach  the  stomach,  as  they  constantly 
do  when  the  usual  anastomosis  is  done.  The  principle  of  the 
Y-anastomosis  is  of  value  in  certain  ()Thcr  intestinal  anastomoses. 

The  Vicious  Circle  after  Gastrojejimostomy  is  rarely  seen  at  present. 
When  a  long  jejunal  loop  was  used  it  was  not  infrequent.  Probably 
the  cause  is  obstruction  of  the  duodeno-jejunal  loop  at  the  point  of 
anastomosis.  The  patient  vomits  persistently  after  operation,  and 
if  repeated  lavage  proves  ineffectual  the  abdomen  may  have  to  be 
re-opened  to  relieve  the  obstruction.  The  best  treatment  is  an  entero- 
anastomosis  between  the  afferent  and  efferent  limbs  of  the  jejunal 
loop.  The  pylorus  also  should  be  occluded  by  a  purse-string  suture, 
if  still  patulous. 

A  peptic  ulcer  of  the  jejunum  occasionally  forms  at  or  below  the 
gastrojejunal  anastomosis.    It  is  seldom  recognized  except  by  hemor- 


OI'KUATIONS  ON    TIIK  STOMACH 


881 


rha^v  or  p(.'rt\)rati()ii.  Treatiuc'iit  of  these  complications  is  the  same 
as  that  of  gastric  or  duodenal  ulcer.  It  may  be  necessary  to  make  a 
new  gastrojejunostomy  opening.  This  complication  is  rare  after  the 
no-loo{)  method  of  j)osterior  gastro-enterostomy. 


Fig.  859. — Diagram  of  posterior  gastro-jojunostomy  in  Y, 


Gastrectomy. — A  portion  or  the  whole  of  the  stomach  may  be 
removed.  In  pylorectomy  the  pylorus  and  some  of  the  pyloric  antrum 
are  removed;  this  operation  is  employed  only  in  cases  of  benign 
disease.  In  every  case  of  malignant  disease  the  whole  of  the  lesser 
curvature  ought  to  be  removed,  and  the  operation  is  called  a  partial 
gastrectomy,  the  stomach  being  divided  at  the  Hartmann  or  ^Mikulicz 
line  (Fig.  800).  If  the  stomach  is  removed  as  far  as  the  Mayo  line,  the 
operation  is  known  as  subtotal  gastrectomy;  while  if  the  entire  stomach 
is  removed  from  esophagus  to  duodenum,  the  procedure  is  worthy  the 
name  of  total  gastrectomy.  Circular  or  cylindrical  gastrectomy  desig- 
nates an  operation  by  which  the  central  portion  of  the  stomach, 
including  the  entire  circumference,  is  removed. 

Partial  Gastrectomy. —  BiUroiKs  First  Method {IS>HI). — This  operation 
is  very  rarely  employed.  After  removal  of  the  diseased  area,  an  end- 
to-end  anastomosis  is  made  between  the  duodenum  and  the  remaining 
portion  of  the  stomach  (Fig.  861).  As  the  circumference  of  the  latter 
56 


SS2 


SLRdERY   OF    THE   GASTRO-INTESTI XAL    TRACT 


is  much  greater  tlian  that  of  the  duodenum  leakajje  is  very  apt  to 
occur  at  the  "angle"  of  the  suture  lines.  Kocher  (1891)  modified  the 
Billroth  I  technique  by  implanting  the  duodenum  into  the  posterior 
wall  of  the  stomach,  thus  avoiding  the  deadly  angle,  and  completely 
closing  the  cut  surface  of  the  stomach. 


Fig.  860. — Stomach,  showing  the  Hart- 
mann  (H),  Mikulicz  (M),  and  Mayo  (M') 
lines. 


Fig.  861. — Partial  gastrectomj^  by  Bill- 
roth's  first  method. 


Bill  roth's  Second  Method. — In  this  both  the  duodenum  and  stomach 
are  closed  completely,  and  the  operation  is  terminated  by  a  typical 
ga.strojejunostomy.  In  Billroth's  original  technique  an  anterior  gas- 
trojejunostomy was  done;  but  whenever  possible  posterior  gastro- 
jejunostomy is  preferable. 

The  stomach  is  exposed  through  the  usual  right  rectus  incision, 
and  is  isolated  with  gauze.  "The  coronary  artery  is  identified,  doubly 
ligated  and  divided,  close  to  the  cardiac  orifice  of  the  stomach.  The 
finger  is  passed  tlirough  the  gastrohepatic  omentum  into  the  lesser 
peritoneal  cavity,  and  the  gastrohepatic  omentum  is  ligated  in  sections 
fairly  close  to  the  transverse  fissure  of  the  liver.  By  cutting  through 
the  gastro-hepatic  omentum  the  surgeon  reaches  the  pyloric  artery, 
which  is  doubly  ligated  and  cut.  The  finger  is  then  passed  down 
behind  the  pylorus,  and  the  right  gastro-epiploic  artery  is  identified 
below  the  pylorus;  this  artery  is  ligated  but  not  cut.  Hemostatic 
forceps  are  then  applied  to  the  gastro-colic  omentum,  and  as  they 
are  applied  this  structure  is  divided  between  them,  beginning  at  the 
pylorus  and  passing  along  the  upper  border  of  the  transverse  colon 
until  the  point  is  reached  at  which  it  is  proposed  to  divide  the  stomach. 
This  point  should  be  two  inches  to  the  left  of  the  visible  malignant 
growth.  When  this  point  has  been  reached  the  left  gastro-epiploic 
artery  is  ligated  just  to  the  left  of  the  proposed  gastric  incision.    In 


OI'I'lliAllONS  ON    THE  STOMACH 


ss.s 


|)laciii<i;  tlic  lu'iii(»st;its  on  {\\v  ^^astro-colic  oiuciituiii,  jfrciit  care  is  to 
be  taken  to  a\ oid  the  middle  colic  artery  and  its  branches.  Tlie  portion 
of  stomach  to  he  rcmox'cd  is  now  completclx'  Treed  alon<!;  its  curva- 
tures, and  remains  attached  only  to  the  duodenum  and  the  body  of 
tlie  stomach.  Tlie  lesser  jjcritoneal  cavity  can  now  he  i)rotected 
thoroughly  hy  sterile  gauze  compresses.  A  clamp  with  ruhher- 
covered  blades  is  now  applied  to  the  duodenum  about  one  inch  beyond 
the  portion  xisibly  diseased,  and  an  ordinary  clamp  is  a])])licd  just  to 
the  i)yloric  side  of  the  first  clamp.  The  duodcinnn  is  then  dixidcd 
between   the  two,  tlu'  section  cutting  also  the  right  gastro-epiploic 


Fig.  8G2. — Partial  gastrectomy:  the  duodenum  has  been  divided,  and  the  chimps  are 
in  place  for  the  gastric  section.     (Deaver  and  Ashhurst.) 


artery  (already  ligated)  below  the  pylorus.  The  entire  portion  of  the 
stomach  to  be  excised  can  now  be  turned  to  the  patient's  left.  The 
duodenal  stump  is  closed  first  by  a  through-and-through  iodized 
catgut  suture;  before  the  occluding  clamp  has  been  removed  a  purse- 
string  suture  of  linen  is  applied  on  the  distal  (duodenal)  side  of  the 
clamp;  the  clamp  is  then  removed,  and  by  catching  the  duodenal  wall 
in  two  places  with  dissecting  forceps  the  sutured  end  of  the  duodenum 
is  inverted  and  the  purse-string  suture  is  drawn  tight  and  tied  (Fig. 
862).  The  gastro-colic  omentum  is  then  ligated,  and  the  hemostatic 
forceps  removed.  Rubber-covered  gastrectomy  clamps  are  then  applied 


884  SUKGEIiY  OF   THE  GASTRO-INTESTJ NAL   TRACT 

across  the  stomach  from  the  greater  to  the  lesser  curvature,  at  least 
two  inches  to  the  left  of  the  visible  malignant  growth.  Clamps  with 
a  screw  lock  at  the  end  of  the  blades,  as  in  Kocher's  clamps,  are  safest. 
About  three-fourths  of  an  inch  to  the  right  of  this  occluding  clamp 
an  ordinary  forceps  is  applied,  and  the  stomach  is  divided  between 
the  two  with  the  thermo-cautery.  The  excised  portion  being  removed, 
a  through-and-through  suture  of  iodized  catgut  is  inserted  through 
the  margins  of  the  gastric  walls  which  protrude  from  between  the 
blades  of  the  rubber-covered  clamp.  It  is  well  to  grasp  these  margins 
at  one  or  more  points  with  forceps  to  prevent  their  retracting.  When 
the  through-and-through  sutures  have  been  completed,  the  clamp  is 
remo\'ed,  and  a  continuous  sero-serous  suture  is  applied  burying  the 
first  row."  (Deaver  and  Ashhurst.)  A  posterior  gastrojejunostomy  is 
then  done,  the  viscera  replaced,  and  the  great  omentum  is  drawn  up 
to  cover  the  space  left  by  the  removal  of  the  stomach. 

Subtotal  Gastrectomy  differs  from  the  oj^eration  just  described  only 
in  the  greater  amount  of  stomach  removed.  Sometimes  this  is  so  great 
that  only  an  anterior  gastrojejunostomy  can  be  done  to  complete 
the  operation. 

Total  Gastrectomy  proceeds  along  the  same  lines  as  partial  gas- 
trectomy; the  duodenum  should  be  sutured  to  the  esophagus  (end  to 
end)  before  the  stomach  is  completely  cut  away  from  the  latter.  If 
the  duodenum,  even  after  mobilization  (p.  933)  cannot  be  made  to 
reach  the  esophagus  without  undue  tension,  a  loop  of  the  jejunum 
should  be  employed  instead,  being  drawn  through  the  transverse 
meso-colon.  The  Y-anastomosis  of  Uoux  is  valuable  under  such 
circumstances. 

SURGERY  OF  THE  INTESTINES. 

Intestinal  Obstruction,  or  Ileus,  may  be  caused  by: 

1.  Paralysis  of  the  muscular  tunic  of  the  bowel  {adynainlc  ohsf ruc- 
tion) from  bacterial  toxins,  as  frequently  seen  in  cases  of  peritonitis 
(p.  808),  or  from  lesions  of  the  spinal  cord  (p.  597). 

2.  Spasticity  of  the  muscular  tunic  {dynamic  obstruction)  which  is 
very  rare,  and  occurs  chiefly  in  cases  of  lead  or  tyrotoxicon  poisoning. 

3.  Occlusion  of  the  intestine  by  (a)  Changes  within  the  lumen  of  the 
bowel,  such  as  impaction  of  feces,  a  gall-stone,  or  other  foreign  body 
(obturation),  (b)  Changes  in  the  wall  of  the  bowel,  such  as  congenital 
malformations,  or  gradual  occlusion  by  a  tumor  or  contracting  cicatrix. 
(e)  Pressure  from  the  outside,  by  tumors  of  neighboring  organs. 

4.  Strangulation  of  the  intestine  by  (a)  Peritoneal  bands  or  adhe- 
sions,    (b)  Intussusception,     (c)  Volvulus.    {(I)  Internal  Hernia.' 

Cases  of  intestinal  obstruction  are  conveniently  divided  into  two 
classes,  acute  and  chronic.  Though  cases  of  chronic  obstruction 
frequently  become  acute,  and  though  acute  cases  very  rarely  may 

1  Strangulation  uf  external  hernia  lui.s  l)e(;n  considered  at  p.  7()1. 


IXTKsriXAL   OHSTHrcriOS  NS.") 

hfcome  chronic,  there  is  in  most  cases  no  difficulty  in  distiniinishing 
one  from  tlie  other.  'I'he  acute  cases  are  those  (hie  to  .stm/Kjiilafion 
or  to  ohfurafion  from  the  sudden  impaction  of  foreifjii  bodies.  The 
chronic  cases  are  ahnost  solely  those  due  to  gradual  occlusion  of  the 
lumen  of  the  howel  hy  a  tumor  or  cicatrix  or  from  pressure  from  with- 
out. Ihnamic  oh.struction  is  .scarcely  a  surjrical  afi'ectioii.  while  ady- 
namic «)l).struction  has  been  sufficiently  di.scussed  with  the  subject 
of  peritonitis.  Obstruction  from  congenital  malformations  usually 
occurs  at  the  rectum  or  anus,  and  is  discussed  at  ]).  901.  Affections 
of  Meckel's  diverticulum  are  discussed  at  p.  S91. 

Acute  Intestinal  Obstruction. — The  gravity  of  this  condition 
depend>  not  merely  upon  the  arrest  of  the  fecal  current  but  upon 
constitutional  sxmptoms.  The  higher  the  obstruction  occurs  in  the 
intestinal  tract  the  more  quickly  developed  and  the  more  pronounced 
are  these  constitutional  symptoms.  Tlie  collapse  and  other  consti- 
tutional symptoms  of  acute  dilatation  of  the  stomach  have  already 
been  noted  (p.  SOO).  The  exact  cause  of  such  constitutional  symptoms 
has  not  been  determined,  in  spite  of  much  recent  experimental  work 
by  Draper.  Hoguet,  and  others. 

Symptoms. — The  local  symptoms  are  well  marked  and  easily  recog- 
nized: they  are  pain;  vomiting;  obstipation,  with  no  passage  of  flatus 
by  the  rectum;  disordered  peristalsis  which  is  always  audible 
when  the  ear  is  placed  on  the  belly,  and  may  be  visible  if  the 
abdominal  wall  is  thin;  and  finally  distention  of  the  abdomen. 
The  pain  is  characteristic;  it  is  sudden  in  onset,  very  severe, 
often  causes  the  patient  to  cry  out,  and  is  intermittent.  ^Yhen  it 
ceases  the  patient  feels  and  may  look  perfectly  well,  but  it  returns 
unexpectedly  and  with  great  suddenness.  In  most  cases,  within  a 
day  or  so,  the  pain  becomes  constant,  and  is  more  or  less  localized 
to  the  seat  of  ob.struction.  Sudden  cessation  of  a  fixed  pain  usually 
indicates  the  occurrence  of  gangrene.  The  vomiting  is  projectile 
in  type:  there  is  little  or  no  nau.sea,  and  the  patient,  unprepared  by 
previous  nausea,  suddenly  and  unexpectedly  spues  forth  a  quantity 
of  vomitus  all  over  everything.  At  first  the  vomiting  is  not  very 
frequent;  the  gastric  and  fluodenal  contents  are  rejected  first,  later 
the  upper  intestinal  contents,  and  shortly  before  death  matter  that 
appears  fecal  may  be  vomited.  Though  repeated  enemas  may  secure 
an  evacuation  from  the  bowel  below  the  obstruction,  no  normal  move- 
ment occurs,  and  no  flatus  is  passed  by  rectum  at  any  time.  Eventu- 
ally the  abdomen  becomes  tympanitic  and  distended  and  the  peris- 
taltic movements  sometimes  may  be  observed  to  be  arrested  at  a 
fixed  spot,  where  the  obstruction  is  located.  The  bowel  above  the 
obstruction  becomes  much  dilated  and  undergoes  the  changes  already 
described  in  strangulated  hernia,  that  below  the  obstruction  is  col- 
lapsed. 'The  virulence  of  the  bacteria  above  the  obstruction  is  much 
increased,  and  the  altered  intestinal  wall  is  more  readily  traversed  by 
them,  and  thus  peritonitis  supervenes  even  before  gangrene  or  per- 
foration of  the  strangulated  bowel  takes  place.    Xot  until  this  time  is 


sso 


SURGERY  OF   THE  GASTRO-INTESTINAL   TRACT 


the  temperature  noticeably  elevated,  and  though  at  this  time  also  the 
pulse  becomes  rapid  and  wiry,  in  the  early  stages  of  intestinal  obstruc- 
tion the  pulse  often  is  fuller  and  slower  than  normal.  In  this  advanced 
stage  the  diagnosis  is  difficult  between  i)erit()nitis  with  secondary 
obstruction,  and  primary  obstruction  terminating  in  peritonitis.  The 
clinical  picture  is  that  of  the  late  stages  of  peritonitis  (p.  800).  In 
cases  of  acute  intestinal  obstruction,  unrelieved  by  operation,  death 
usually  occurs  within  a  week. 

Diagnosis. — The  impaction  of  a  biliary  ndruJus  or  other  foreign  body 
may  be  suspected  from  the  history  of  the  case,  and  from  the  inter- 
mittent character  of  the  symptoms,  since  the  obstruction  seldom  is 
absolute  at  first,  the  gall-stone  shifting  its  position  within  the  lumen 
of  the  gut  from  time  to  time.  It  is  most  apt  to  become  impacted  in 
the  lower  ileum.  Obstruction  from  peritoneal  adhesions,  resulting  in 
kinks  of  the  intestine  or  constriction  beneath  a  band  of  organized 
lymph  is  most  frequent  in  children  or  young  adults  who  give  a  history 
of  one  or  more  attacks  of  peritonitis  or  of  an  abdominal  operation. 
The  symptoms  usually  are  very  severe  and  collapse  is  marked.  Intus- 
susception is  rare  in  those  more  than  two  years  of  age;  usually  it  results 


Fig.  863. — Diagram  of  an  intussusception:  A,  the  apex  of  the  intussusceptum; 
C,  the  collar  of  the  intussuscipiens. 


from  violent  peristalsis  induced  by  enteritis;  the  presence  of  intestinal 
parasites,  polj^pi,  or  enlarged  mesenteric  lymph  nodes  may  act  as 
predisposing  causes.  The  most  frequent  form  of  invagination  is  the 
ileo-cecal.  The  portion  of  intestine  which  is  sucked  down  into  the 
lumen  of  that  below  is  known  as  the  intussusceptnm,  while  that  which 
receives  it  is  called  the  intnss'iiscipien.s  (Fig.  803).  The  apex  of  the 
intussusceptum  is  that  part  which  leads  the  way  in  the  lumen  of  the 
bowel  (in  an  ileo-cecal  intussusception  the  apex  of  the  intussusceptum 
is  formed  by  the  ileo-cecal  valve) ;  while  the  neck  is  the  portion  which 
enters  the  collar  of  the  intussuscipiens.  The  characteristic  symptom 
of  this  form  of  intestinal  obstruction  is  the  constant  desire  to  defecate, 
with  the  passage  of  blood  and  mucus  from  the  rectum.  Occasionally 
the  finger  introduced  into  the  rectum  will  feel  the  apex  of  the  intus- 
susceptum; and  in  many  cases  it  is  possible  to  recognize  a  sausage- 
shaped  tumor  in  the  right  or  left  hypochondrium,  the  right  iliac  region 
being  flattened  (Dances  sign,  1820),  owing  to  the  migration  of  the 
invaginated  bowel  along  the  course  of  the  ascending  and  transverse 
colon.  Volvidus  is  most  frequent  in  adults,  especially  in  the  aged, 
and  is  said  to  occur  oftenest  in  the  sigmoid  flexure;  but  in  my  own 


INTESTINAL  OJiSTUl  (  TION 


SS7 


cxiHTiciKr  till'  siiinll  intestine  has  hcen  oftencst  inxolxed.  The  ohstrnc- 
tion  is  (hie  to  twisting'  ot"  the  howel  around  its  mesentery;  unless  an 
are  of  three-Hlths  of  a  circle  is  descrihed  stranmihition  does  not  occur. 
The  twist  usually  takes  j)lace  in  contra-clockwise  direction,  the  oral 
linii)  of  the  howel  i)assinf^  ahove  and  to  the  right  of  the  aboral  limb. 
\ Olvulus  is  predisposed  to  hy  elonj^ation  of  the  mesentery  or  hy  fixa- 
tion of  the  intestine  at  any  point  hy  adiiesions,  thus  permitting;  acti\'e 
peristalsis  to  throw  the  oral  limb  over  the  aboral  portion  which  is 
fixed.  Rectal  examination  sometimes  reveals  a  distended  coil  of  bowel 
in  the  recto-vesical  pouch;  or  the  distended  loop  may  be  {)ali>able 
throuiih  the  abdominal  wall.  Jnlcrnal  hernia  may  occur  in  any  of  the 
recesses  or  pockets  of  tlie  j)eritoneum,  especially  the  duodeno-jejunal 
fossae;  less  often  in  the  pericecal  fossje  or  the   meso-sigmoid  fo.ssa. 


Fifi.  864. — Strangulation  of  a  loop  of  ileum  through  a  hole  in  its  mesentery.  A 
Meckel's  diverticulum,  adherent  to  the  anterior  abdominal  wall  prevented  more  intestine 
from  passing  through  the  mesentery.     Episcopal  Hospital 

Hernia  through  the  foramen  of  Winslow  is  rare,  as  is  a  hernia  through 
a  congenital  or  acquired  opening  in  the  mesentery  of  the  small  intestine 
(Fig.  S04).  The  possibility  of  a  hernia  through  the  transverse  meso- 
colon after  the  operation  of  gastro-jejunostomy  has  been  mentioned 
(p.  880).  The  diagnosis  of  these  internal  hernite  is  difficult;  usually  the 
symptoms  are  gradual  in  onset,  and  many  cases  belong  to  the  category 
of  chronic  rather  than  to  that  of  acute  obstruction.  Sometimes  as 
the  hernia  increases  in  size  it  may  be  discovered  on  palpation,  or 
borborygmi  and  subjective  symptoms  may  point  to  the  region  of  the 
abdomen  involved. 

Treatment. — -The  first  and  most  important  item  of  treatment  is 
to  avoid  ])iir(jafivrs.  Even  if  the  presence  of  obstruction  is  uncertain, 
the  administration  of  any  form  of  la.xative  or  purge  is  absolutely  con- 


88S  ^URdERY  OF   THE  (;ASTRO-INrESri NAL   TRACT 

traiiidicated,  so  long  as  the  ])()ssil)ility  of  acute  intestinal  obstruction 
cannot  be  excluded.  It  is  perfectly  proper  to  use  enemas,  in  order  to 
secure  an  evacuation;  but  purgatives  are  not  only  useless,  in  that  they 
never  relieve  the  obstruction,  but  they  are  intensely  harmful.  They 
arouse  peristalsis,  which  results  in  increase  of  the  strangulation,  and 
they  increase  the  amount  of  the  intestinal  contents  above  the  obstruc- 
tion. Some  surgeons  recommend  the  use  of  eserin,  in  cases  of  obstruc- 
tion seen  early;  they  argue  that  while  it  arouses  peristalsis  it  does 
not  cause  an  exudation  into  the  intestinal  canal  as  most  other  purga- 
tives do;  and  they  believe  that  it  will  do  good  in  cases  of  adynamic 
obstruction,  and  that  where  the  nature  of  the  obstruction  is  uncertain 
its  use  will  aid  the  surgeon  in  reaching  a  diagnosis,  since  if  nothing 
is  accomplished  or  the  patient  is  made  worse  it  may  be  assumed  that 
the  obstruction  is  not  adynamic  but  mechanical.  This  teaching  I 
regard  as  pernicious.  Though  I  have  seen  eserin  blow  the  wind  out 
of  a  belly  with  great  activity,  I  have  failed  to  observe  that  such  an 
occurrence  hastens  recovery;  and  I  have  also  seen  intestinal  perfora- 
tion caused  by  the  violent  peristalsis  induced  by  eserin.  It  cannot 
be  too  strongly  impressed  upon  the  student  that  in  cases  of  adynamic 
obstruction  the  patient  is  not  ill  because  his  abdomen  is  distended, 
but  his  abdomen  is  distended  because  he  is  ill. 

If  there  is  any  doubt  as  to  the  diagnosis,  much  less  damage  will  be 
done  the  patient  by  resort  to  immediate  laparotomy  than  by  pro- 
crastination; and  when  operation  is  once  seen  to  be  indicated,  there 
should  be  no  delay.  The  patient  will  not  get  any  better  by  waiting. 
But  it  is  always  well  to  wash  out  the  stomach  before  operation.  This 
will  prevent  vomiting  and  perhaps  aspiration  of  gastric  contents  into 
the  lungs  while  the  patient  is  under  ether. 

Operation. — Unless  the  site  of  obstruction  is  definitely  known,  the 
incision  should  be  median,  below  the  umbilicus.  Do  not  let  the  dis- 
tended intestines  escape  from  the  abdomen.  Find  the  transverse 
colon;  it  is  recognized  by  the  attached  omentum.  If  it  is  distended, 
the  obstruction  is  lower,  probably  in  the  sigmoid  or  rectum,  rarely 
at  the  splenic  flexure;  if  it  is  collapsed,  the  obstruction  probably  is  in 
the  small  intestine.  Try  to  find  some  collapsed  small  intestine  and 
trace  it  upward  to  the  obstruction.  If  evisceration  becomes  necessary, 
the  eviscerated  intestines  should  be  covered  in  hot  wet  towels,  and 
these  should  be  kept  hot  and  wet  by  constant  irrigation  with  saline 
solution  at  a  temperature  of  about  115°  F.  If  the  bowel  above  the 
obstruction  is  very  much  distended  it  should  be  emptied  of  its  highly 
infectious  contents  by  aspiration  or  incision.  Monks  advocates  passing 
a  glass  tube  up  the  lumen  of  the  distended  intestine,  and  crowding  as 
many  coils  of  bowel  upon  it  as  possible,  to  aid  in  securing  evacuation. 
I  have  tried  this  method  on  several  occasions,  but  have  not  found  it 
eflfectual.  If  the  condition  of  the  patient  is  very  bad,  the  operation 
may  be  terminated  by  establishing  a  false  anus  abo\'e  the  obstruction, 
as  in  cases  of  acute  obstruction  superimposed  upon  clironic  obstruction 
(p.  890) ;  and  in  almost  moribund  patients  life  is  occasionally  saved 


/.vv'A'.sv/.v.i/.  oiisrurc'i'iox  sso 

l)y  (tpciiiiii;-  the  fir.^t  (list(Mi(l(Ml  coil  of  iiitcstiiic  wiiicli  i)rt'S(>iits  itself 
without  Miiikiiiic  any  search  whatexer  for  the  ohstriictioii;  this  con- 
stitutes the  old  operation  of  nitrrotoni!/.  It  has  recently  been  revixcd 
l)\  Kro^ius  1 1!)1  1 ).  If  obstruction  is  due  to  the  iniiMtrtion  of  a  fort'tfiii 
1x1(1 1/,  it  should  he  dislodged  if  jiossihie  and  removed  throuf^h  an  inci- 
sion  in  healtliN    intestine. 

If  the  ol)struction  is  due  to  ktnkiiKj  from  (tdhcsion.s,  these  usuallx' 
may  he  se])arated  with  the  fingers  or  gauze  dissection;  distinct  hands 
must  he  cut.  The  denuded  areas  on  tlie  intestines  should  be  inverted 
by  sero-serous  sutures,  or  should  be  covered  with  omentum.  If  the 
adhesions  an*  \-ery  wi(les])rea(l  and  the  bowel  very  friable,  a  short- 
circuiting  operation  (p.  cSD.j)  may  be  necessary. 

In  cases  of  Infuss^isception,  efforts  at  reduction  should  be  made  l)y 
pushing  the  intussusceptum  l)ack,  not  by  attempts  to  i)ull  it  out 
from  aboNc.  The  latter  method  rarely  is  successful,  and  may  be  pro- 
ductive of  much  damage.  If  reduction  proves  impossible,  the  intus- 
suscipiens  may  be  incised  longitudinally  and  the  intussusceptum 
removed,  the  incision  being  closed,  and  the  neck  and  collar  of  the 
invaginated  bowel  being  sutured  together  as  in  Maunsell's  method 
of  end-to-end  anastomosis  (Fig.  829).  Enterectomy  rarely  is  justi- 
fiable in  this  or  any  form  of  acute  obstruction;  the  establishment 
of  a  false  anus  abo\e  the  obstruction  (if  this  is  not  too  high  in  the 
intestinal  tract)  or  a  short-circuiting  operation  will  be  preferable. 
Occasionally  the  gangrenous  intussusceptum  separates  as  a  slough 
and  is  discharged  by  rectum.  The  operative  mortality  is  about  33 
per  cent. 

In  cases  of  voh-ulus,  the  bowel  should  be  untwisted,  and  if  the  condi- 
tion of  the  patient  permits,  it  is  well  to  take  a  reef  in  the  redundant 
mesentery  or  to  attach  the  sigmoid  to  the  parietal  peritoneimi,  so  as  to 
prevent  recurrence. 

Chronic  Intestinal  Obstruction. — This  is  most  often  the  result  of 
fecal  impaction,  benign  or  malignant  stricture,  or  widespread  peri- 
toneal adhesions  which  interfere  with  peristalsis  without  causing 
strangulation. 

In  fecal  impaction,  which  occurs  oftenest  in  the  rectum  or  sigmoid, 
rarely  in  the  transxerse  colon  or  cecum,  there  is  obstinate  constipa- 
tion, with  slight  intermittent  colicky  pains  from  disordered  peristalsis; 
sometimes  a  mass  can  be  felt  through  the  abdominal  wall,  which  is 
recognized  as  fecal  from  its  doughy  consistency.  Vomiting  (never 
stercoraceous)  may  occur  during  an  acute  attack;  and  watery  diarrhea 
often  follows  relief  of  the  obstruction.  Treatment  comprises  the  use 
of  repeated  enemas,  administered  in  the  Trendelenburg  or  knee- 
chest  posture,  and  evacuation  of  fecal  masses  from  the  rectal  ampulla 
by  the  finger  if  necessary.  When  once  the  impaction  is  relieved,  it 
is  safe  to  give  purges;  as  long  as  any  acute  symptoms  persist  opium 
and  belladonna  may  be  of  use  in  relaxing  intestinal  spasm. 

In  chronic  obstruction  from  a  cicatrix  or  tumor  of  the  intestine, 
the  symptoms  are  much  the  same  as  in  fecal  impaction,  but  as  a  rule 


890 


SURGERY   OF    THE   GASTRO^INTESTINAL    TRACT 


no  tumor  can  he  felt.  After  many  attacks  of  partial  obstruction,  this 
is  prone  to  become  acute  and  complete  at  the  last.  If  palliative  treat- 
ment (enemas)  proves  unavailing  the  surgeon  should  open  the  abdo- 
men, and  in  the  presence  of  acute  obstruction  should  content  himself 
with  making  a  false  anus  above  the  seat  of  the  tumor;  if  there  is  no 
evidence  of  acute  obstruction  the  tumor  or  cicatrix  may  be  resected, 
but  such  a  course  almost  always  leads  to  death  from  peritonitis  unless 
the  bowel  above  the  tumor  is  unobstructed.  If  the  tumor  is  in  the 
rectum,  a  sigmoid  anus  may  be  made  in  the  left  iliac  region  (Littre's 
operation,  1710);  but  if  the  tumor  is  higher  in  the  large  intestine 
cecostomy  (Fig.  865)  should  be  done  in  the  right  iliac  region  (Pillore, 
1776).  For  obstruction  in  the  small  intestine,  which  is  rare,  a 
short-circuiting  operation  is  preferable  (entero-enterostomy). 


Fui.  SOS. — Cecf)stf)nij',  for  .■icutc  intestinal  Dlisiruction.  ul  dw  week's  flurat.inn,  super- 
voniiis  on  chronic  obstruction  of  twelve  years'  standing.  Paul's  tube  in  cecum.  Stricture 
of  sigmoid,  in  woman  of  fifty-three  years,  following  injury  in  childbirth  thirteen  years 
ago.      (See  page  911.)      Episcopal  Hospital. 


Mesenteric  Thrombosis  and  Embolism. — Thrombosis  of  the  mesen- 
teric vessels  occurs  in  many  cases  of  intestinal  obstruction,  as  the  result 
of  strangulation.  But  thrombosis,  and  rarely  embolism,  may  occur 
as  a  primary  condition,  from  the  same  causes  which  produce  similar 
conditions  in  other  parts  of  the  body.  The  sytnptoms  are  not  unlike 
those  of  acute  intestinal  obstruction,  except  that  pain  occasionally  is 
inconspicuous  in  cases  of  thrombosis;  peritonitis  develops  more  rapidly 
than  in  intestinal  obstruction;  and  there  are  evidences  of  hemorrhage 
into  the  intestinal  tract,  with  bloody  diarrhea  or  \'omiting.  Diagnosis 
is  difficult.  Treatment  comprises  immediate  laparotomy  and  resection 
of  the  affected  bowel,  which  quickly  becomes  gangrenous.  Among  22 
complete  operations  collected  by  Zesas  (1910),  there  were  7  recoveries. 
If  the  condition  of  the  patient  renders  resection  impossible,  the  gut 
may  be  tamponed,  or  may  be  drained;  but  incomplete  operations 
almost  alwavs  terminate  fatallv. 


IXTKSriXA L   I'KRFOUA 770.V 


891 


h'l.Wlll.l   '•  '■!.     .■' 


^>)vv 


Meckel's  diverticulum,  the  remains  of  the  oinphalo-inesenteric 
(hut,  is  loiiiid  in  al)()nt  2  jht  eent.  of  bodies  which  conie  to  autopsy. 
It  is  attached  to  the  lower  ileum,  within  a  few  feet  of  the  cecum,  and 
usually  springs  from  the  anti-mesenteric  border  of  the  gut.  It  is 
about  the  size  of  the  finger,  and  may  be  unadherent,  or  may  be  attached 
to  the  umbilicus  (see  I'mbilical  Fistula)  or  to  some  other  point  in 
the  abdomen.  It  is  most  apt  to  cause  trouble  if  adhereiit,  acting  as 
a  band  under  or  around  which  the  intestine  becomes  strangulated. 
If  adherent  to  the  umbilicus,  volvulus  of  the  small  intestine  is  fre- 
(juent,  causing  torsion  and   per- 


ha])s  strangulation  of  the  di\er- 
ticulum  (Fig.  NdO).  If  unat- 
tached, its  chief  afl'ection  is 
acute  inflammation,  which  in 
its  pathogenesis,  symptoma- 
tology and  treatment  resembles 
appendicitis. 

Diagnosis. — The  presence  of 
a  Meckel's  diverticulum  may  be 
suspected  if  the  umbilical  cica- 
trix is  abnormal.  I  have  twice 
been  able  to  make  the  correct 
diagnosis  before  opening  the 
abdomen,  by  heeding  this 
maxim.  Trouble  is  especially 
apt  to  arise  about  the  age  of 
puberty. 

Treatment. — It  is  best  to  excise  the  diverticulum,  at  the  same  time 
doing  what  is  necessary  to  the  strangulated  intestine. 

Umbilical  Fistula. — If  the  omphalo-mesenteric  duct  remains  patu- 
lous, a  fistula  is  present  at  the  umbilicus.  This  may  discharge  feces, 
or  if  very  small  only  mucus.  In  some  cases  the  discharge  resembles 
gastric  juice  and  it  is  uncertain  whether  the  mucosa  from  which  the 
discharge  comes  is  an  excluded  part  of  Meckel's  diverticulum,  or 
neoplastic  ('adenomatous)  in  nature  CDenuce,  1908).  The  best  treat- 
ment is  extirpation  of  the  diverticulum. 

AflFections  of  the  Urachus  are  rliscussed  at  p.  968. 

Internal  Fistulae  of  the  Intestinal  Tract  usually  are  the  result  of 
peritonitis,  malignant  disease,  or  tuberculosis.  Occasionally  they 
result  from  injury.  The  existence  of  a  fistula  between  the  gall-hladder 
and  the  intestine  may  be  inferred  if  a  large  gall-stone  is  passed  by  rec- 
tum or  lodges  in  the  intestine;  such  fistula?  often  close  spontaneously 
and  rarely  cause  symptoms.  A  gastro-colic  fistula  gives  evidence  of 
its  presence  chiefly  by  the  development  of  lienteric  diarrhea  and 
fecal  vomiting.  Other  forms  of  internal  fistula  are  rare  and  do  not 
cause  characteristic  symptoms.  Gastro-colic  fistula?  scarcely  ever 
close  spontaneously,  and  early  operation  is  indicated.  The  best  plan 
is  to  separate  the  stomach  and  colon  and  repair  the  perforation  in 


Fig.  866. — Strangulation  of  Meckel's  di- 
verticulum, adherent  to  umbilicus.  Age 
forty-six  years;  duration  two  days.  Epis- 
copal Hospital. 


<S92  SURGERY  OF   THE  (;ASTR0-I XTESTJ X AL   TRACT     - 

each.  But  this  is  not  always  possible.  Alternate  inethods  are  (I) 
section  of  the  colon  on  each  side  of  the  fistula,  and  bilateral  exclusion 
(p.  895)  of  the  portion  of  bowel  containing  the  fistula,  leaving  it  as  a 
pouch  attached  to  the  stomach,  and  reuniting  the  colon  above  and 
below  the  seat  of  disease;  (2)  short-circuiting  the  fecal  current  by  a 
colo-colostomy  (above  and  below  the  fistula )  or  by  ileo-sigmoidostomy ; 
but  neither  of  these  y)lans  is  \-ery  satisfactory. 

Intestinal  Perforation  in  Typhoid  Fever  occurs  in  about  2.5  per  cent. 
of  cases.  It  is  most  frecjuent  during  the  third  or  fourth  weeks  of  the 
disease  and  is  predisposed  to  by  a  mixed  infection  in  the  intestinal 
tract.  The  great  majority  of  perforations  occur  in  the  ileum,  within  a 
ffw  feet  of  the  cecum.  The  important  symptoms  are  abdominal  pain, 
localized  muscular  rigidity,  itwrease  in  the  pulse  rate,  and  often  a  fall 
in  the  temperature  immediately  after  the  perforation.  But  the  patient 
may  be  too  to.xic  to  complain  of  pain,  and  the  other  symptoms  may 
pass  unnoticed  unless  the  physician  and  nur.se  are  constantly  alert. 
Very  soon  rigidity  is  lost,  distention  commences,  and  often  it  is  not 
until  widespread  peritonitis  is  developed  that  the  surgeon  is  asked 
to  see  the  patient.  The  sooner  (operation  is  done,  the  better  the  chance 
of  recovery.  Consent  for  immediate  operati(jn  should  be  obtained 
before  perforation  occurs  if  its  occurrence  seems  probable.  If  a  pre- 
perforative  stage  (peritonitis  without  symptoms  of  perforation)  can 
be  recognized,  it  is  proper  to  open  the  belly  then,  anfl  to  prevent 
perforation  by  invercing  all  ulcers  which  threaten  to  perforate.  Even 
if  no  lesion  is  found  (laparotomie  blanche)  the  patient  is  none  the 
worse  for  the  exploration. 

The  operation  may  be  done  under  spinal  or  local  anesthesia,  but  I 
prefer  a  general  anesthetic  (ether  or  gasj.  The  incision,  about  '^ 
inches  long,  is  made  through  the  right  rectus  muscle,  below  the  umbili- 
cus; and  the  lowest  loop  of  ileum  is  pulled  into  the  wound  and  traced 
upward  until  the  perforation  (there  may  be  more  than  one)  is  found 
or  until  healthy  bowel  is  reached.  When  a  perforation  is  found  it 
should  be  closed  by  a  purse-string  or  other  appropriate  suture  (p. 
829)  in  such  a  way  as  not  to  stenose  the  bowel.  If  the  patient  is  des- 
perately ill  (no  such  patient  is  too  near  death  for  operation  to  offer  a 
chance  of  recovery)  it  is  sufficient  to  drain  the  intestine  above  the  area 
of  disease,  by  a  Paul's  tube  (p.  915),  tamponing  the  necrotic  bowel. 
Drainage  to  the  pelvis  always  should  be  employed,  but  I  consider 
irrigation  of  the  peritoneal  cavity  harmful.  Subsequent  treatment 
is  the  same  as  for  peritonitis. 

In  collective  statistics  (Harte  and  A-hhurst,  1904)  the  mortality 
is  nearly  75  per  cent.;  but  a  few  indi\"idual  operators  report  a  death- 
rate  well  below  ()()  per  cent.  (Montreal  (jeneral  Hospital,  Johns  Hop- 
kins Hospital).  In  my  own  hands  the  mortality  has  been  62.5  per 
cent.;  this  includes  one  patient  who  recovered  after  cholecystectomy 
for  perforation  of  the  (jail-bladder  during  typhoid  fever  (Fig.  S(i7),  and  a 
case  of  recovery  after  removal  of  an  acutely  inflamed  appendix  during 
typhoid  fever. 


I'h-CAL    riS'n  LA 


HWA 


Intestinal  Hemorrhage  in  Typhoid  Fever  is  of  sur<,M(al  interest, 
eliielly  ui  (•(iimect  ioii  with  the  diiij^iKtsis  ot"  pert'oPiit  ion.  In  heinor- 
rhiiye.  tlioutih  there  iii;i\  he  marked  shock,  increase  of  pulse  rate  and 
fall  of  temperature,  there  seldom  is  pain  or  marked  abdominal  ri^iditx'; 
and    usually   the   Mood   a|)|)ears   in   the   stools   within   an    hour   or   so. 


Kiii.  .s()7. 


-fiall-hladder  reinovpd  lij-  cholocystoetomy,  showing  typhoid  pfiforalion. 
(Natural  size.)     Episcopal  Hospital. 


Ill  severe  recurring- hemorrhages,  which  usually  are  fatal,  Harte  (1909) 
advocates  laparotomy;  he  succeeded  in  finding  the  bleeding  spot  by 
the  aid  of  transmitted  light,  and  in  checking  the  bleeding  by  suture. 
Though  his  patients  eventually  succumbed,  he  has  indicated  the 
proper  course  to  pursue  in  such  cases. 


SljlS. — Diagram  of  a  fecal  fistula. 


Fecal  Fistula  and  False  Anus. — If  only  a  small  portion  of  the 
intestinal  contents  (perhaps  only  flatus)  is  passed  from  the  bowel 
through  the  opening  in  the  abdominal  wall,  the  patient  is  said  to  have 
a  fecal  fififiild  (Fig.  SliS) ;  but  if  practically  the  entire  intestinal  con- 
tents are  discharged  in  this  way,  a  false  anus  (Fig.  <S69)  is  said  to 
exist. 

A  fecal  fistula  sometimes  develops  in  a  drained  abdominal  wound 
a  few  days  after  operation  in  cases  where  the  bowel  was  gangrenous, 
but  the  fecal  discharge  usually  ceases  spontaneously  after  removal 
of  the  drainage,  as  the  w^ound  granulates.  Its  closure  is  aided  by  con- 
fining the  patient  to  as  dry  a  diet  as  possible,  and  by  securing  an 
evacuation  through  the  rectum  everv  dav  bv  means  of  an  enema. 


894  SURGERY   OF    THE  GASTRO-IXTESTI X A  L    TRACT 

Purges  arc  coiitraiiidicated.  To  ])revent  excoriation  of  the  skin  around 
the  fistuLa,  it  may  he  i)ainted  with  colloiHon,  with  \\  liitehead's  varnish 
(p.  (338),  or  covered  with  zinc  oxide  ointment.  ^Mineral  bases  shoukl  be 
used  in  all  such  ointments,  as  animal  bases  sometimes  are  digested 
by  the  intestinal  juices. 

A  false  anus  usually  is  an  artefact,  intentionally  produced  by  the 
surgeon  (Fig.  8S3);  though  it  may  also  develop  spontaneously,  by  the 
gradual  formation  of  a  spur  in  a  case  of  fecal  fistula.  It  shows  no  ten- 
dency to  heal,  owing  to  the  presence  of  this  firm  s])ur  between  the  affer- 
ent and  efterent  loops  of  bowel;  operation  almost  always  is  necessary  to 
secure  its  closure.  In  some  cases,  where  it  is  certain  that  the  afferent 
and  efferent  loops  of  bowels  are  in  close  apposition,  it  is  safe  to  destroy 
the  spur  by  passing  one  blade  of  a  clamp  into  each  opening  and  gradu- 
ally tightening  the  clamp  throughout  a  period  of  several  days  until 
pressure  has  caused  a  slough  to  form,  and  converted  the  lumen  of  the 
two  intestines  into  one.  Dupuytren's  enterotome  is  the  type  of 
instrument  employed.     If  this  can  be  satisfactorily  accomplished  the 


Fig.  869. — Diagram  of  a  false  anus,  with  formation  of  a  m.nrkcd  spur. 

external  opening  of  the  fistula  usually  closes  spontaneoulsy.  In  most 
cases,  however,  a  radical  operation  must  be  done.  This  consists  in  dis- 
secting widely  around  the  false  anus,  opening  the  healthy  peritoneal 
cavity,  which  is  well  protected  by  gauze  packs,  and  closing  the  open- 
ing in  the  bowel  by  inversion  of  its  margins  where  this  is  possible; 
and  in  other  cases  by  resection  of  the  affected  bowel,  and  restoration 
of  the  continuity  of  the  intestinal  tract  by  end-to-end  or  lateral  anas- 
tomosis. 

Tumors  of  the  Intestine,  except  of  the  sigmoid  and  rectum  (for 
which  see  page  913) ,  are  quite  rare.  Benign  tumors  are  almost  unknown 
with  the  exception  of  mesenteric  cysts  (see  below).  Hyperplastic 
tuberculosis  and  malignant  tumors  (sarcoma  and  carcinoma)  produce 
symptoms  by  obstructing  the  bowel.  Sometimes  melena  or  enter- 
orrhagia  occurs.  If  the  tumor  is  recognized  as  soon  as  symptoms  of 
chronic  obstruction  appear,  it  is  usually  possible  to  remove  it  by  intes- 
tinal resection  with  fair  prospect  of  ultimate  recovery.  Lymphatic 
extension  generally  occurs  late.  In  malignant  tumors  of  the  small 
intestine  resection  with  end-to-end  or  lateral  anastomosis  may  be  done. 


sch'c/'Hn'  or  tiik  coi.ox  asd  siaMoin 


M).") 


In  carciiioina  ot"  tlu-  (renin  (which  sonictinics  j^ivt's  a  palijahic  tninor 
helorc  ohstruc'tive  syniptoins  arise)  it  is  best  to  resect  tlie  entire 
ileo-cecal  coil  of  intestine  as  hi<i;li  as  the  distrihntion  of  the  middle 
colic  artery.  The  contimiity  of  tlie  intestinal  tract  is  restored  by 
implanting  the  ileum  into  the  transverse  colon  or  the  sigmoid.  If 
resection  is  imix)ssihle  in  any  case  (and  it  never  should  be  attempted 
when  acute  obstruction  has  developed)  a  false  anus  may  be  estab- 
lished above  the  sitt>  of  obstruction;  or  a  short-circuiting  operation 
(Fig.  S70)  or  an  intestinal  exclusion  (Fig.  .S71)  may  be  performed. 


Fiu.  870. — Ileo-sigmoidostomy,  a  typical 
"short-circuitinf?"  operation. 


Fig.  871. — Unilateral  exclusion  of  the 
ascending  colon,  by  implantation  of  the 
ileum  into  the  transverse  colon. 


Mesenteric  Cysts  usually  are  of  embryonal  origin,  and  are  endo- 
theliomatous  in  nature.  Hydatid  cysts,  and  cystic  degenerations  of 
malignant  tumors,  also  occur.  Adhesions  are  common,  but  the 
tumor  usually  is  movable  laterally;  it  is  surrounded  by  a  tympanitic 
area,  and  may  be  crossed  by  a  band  of  tympany.  Its  most  frequent 
site  is  in  the  mesentery  of  the  low^er  ileum.  H.  C.  Deaver  collected 
40  cases  in  1909.  The  proper  treatment  is  extirpation,  which  often 
involves  resection  of  the  overlying  intestine. 

Omental  Cysts  of  the  same  nature  occasionally  occur. 


SURGERY  OF  THE  COLON  AND  SIGMOID. 

Colitis. — Three  types  of  this  disease  may  be  recognized:  (1)  Ordi- 
nary ''catarrhal"  colitis  or  entero-colitis,  without  known  specific 
cause,  due  originally  to  errors  in  diet,  exposure,  etc.  (2)  Bacillary 
dysentery,  due  to  the  B.  dysenteric  of  Shiga,  which  usually  is  an  acute 
disease  and  often  rapidly  fatal,  and  which  is  the  common  epidemic 
form  of  dysentery  wliich  devastates  camps,  prisons,  etc.  (3)  Amebic 
dysentery  caused  by  the  amoeba  dysenteriae  (A.  coli),  which  even 
if  acute  or  subacute  at  first  almost  always  terminates  as  a  chronic 
disease.    It  is  almost  solely  with  the  latter  group  of  cases  that  surgery 


896  SURGERY  OF   THE  GASTRO-INTESTIN AL   TRACT 

is  concerned,  since  except  in  the  rare  event  of  perforation  or  abscess 
formation  the  first  and  second  are  best  treated  medically. 

In  amebic  dysentery  the  entire  colon  or  only  parts  of  it  may  he 
affected.  As  the  slou<jhs  are  cast  off  ulcers  are  left,  and  these  may 
cicatrize  or  perforate,  while  new  ulcers  are  forming  in  other  parts  of 
the  colon.  The  sloughs  may  be  passed  by  rectum  in  large  masses 
(membranous  dysentery).  The  amebse  are  carried  quite  constantly 
in  the  portal  circulation  to  the  liver,  and  hepatic  abscess  (p.  9.3())  is  a 
frequent  sequel. 

Symptoms. — The  disease  may  begin  acutely  or  so  insidiously  that 
the  patient  is  unaware  of  its  existence  and  comes  under  the  surgeon's 
care  first  for  the  liver  complication.  A  history  of  residence  in  the 
tropics  is  then  a  great  aid  in  diagnosis,  though  those  who  have  never 
been  in  the  tropics  may  suffer  from  the  disease.  I'sually  the  ameba 
may  be  found  in  the  stools,  especially  after  purgation.  The  symptoms 
of  the  acute  stages  are  frequent  and  copious  watery  and  bloody  dis- 
discharges  from  the  bowel,  with  much  pain  and  loss  of  weight  and 
strength.  Periods  of  remission  are  common,  })ut  recurrence  of  symp- 
toms is  almost  inevitable. 

Treatment. — The  indications  are  (1)  to  destroy  the  parasites  which 
infest  the  bowel,  and  (2)  to  procure  healing  of  the  intestinal  lesions. 
Dieting,  intestinal  antiseptics,  and  rectal  and  colonic  irrigations,  which 
comprise  the  medical  treatment,  rarely  succeed  in  meeting  these 
indications,  though  they  may  secure  alleviation  or  even  latency  of 
symptoms.  If  symptoms  recur  persistently,  it  is  best  to  resort  to  the 
operation  of  cecostoniy,  or  that  of  appendicostomy  (Weir,  1902);  when 
a  fistula  is  thus  established  in  the  caput  coli,  irrigations  can  be  much 
more  effectively  used,  and  thus  the  operation  affords  a  means  of  killing 
the  parasites  and  of  curing  the  intestinal  lesions.  Cecostomy  is  done 
by  the  method  of  Senn  or  AYitzel,  for  gastrostomy  (p.  <S77);  appen- 
dicostomy is  accomplished  by  detaching  the  meso-appendix  in  part, 
and  suturing  the  appendix  in  the  abdominal  wound  (Fig.  900). 

Pericolitis,  etc. — Of  late  years  numerous  cases  have  been  observed 
at  operation  in  which  there  existed  more  or  less  definite  symptoms  of 
chronic  intestinal  obstruction,  of  chronic  appendicitis,  etc.,  but  in 
which  the  main  pathological  changes  consisted  in  the  presence  of  broad 
bands  or  membranes,  binding  the  cecum  to  the  parietal  peritoneum, 
holding  the  lower  ileum  in  a  kinked  position,  or  fixing  the  sigmoid 
so  as  greatly  to  interfere  with  its  function.  These  membranes  were 
well  described  by  Jabez  X.  Jackson  in  1909  and  are  generally  known 
by  the  name  of  Jackson's  membrane.  The  kink  of  the  ileum  (Fig.  872) 
is  especially  associated  with  the  name  of  Lane. 

It  is  usually  assumed,  rather  by  exclusion  than  from  any  definite 
reasons,  that  these  membranes  are  the  result  of  low  grade  infection. 
Some  are  thought  to  l)e  congenital  in  origin.  But  their  exact  path- 
ogenesis is  not  known. 

Symptoms. — The  symptoms  are  subacute  or  chronic  in  type,  antl, 
according  to  Jackson,  consist  essentially  in  pain  and  tenderness,  con- 


rii  Id  COLITIS 


s\r» 


stipatioii,  miicdiis  discliar^e  from  the  bowel,  meteorisni,  loss  of  weight, 
jiastric  symptoms,  and  "neurasthenia.  " 

Treatment.  'IVeatment  consists  in  (h\ision  of  the  adhesions  and 
careful  peritonization  of  all  denuded  surfaces.  A  diseased  appendix  or 
gall-bladder,  or  other  source  of  infection  should  be  treate<l  appro- 
priately at  the  same  time. 


Fig.  872. — Kink  of  the  ileum  due  to  membrane  binding  it  to  the  cecum,  and  associated 
with  chronic  appendicitis.  The  appendix  was  much  twisted  and  occupied  a  deep  sub- 
cecal fossa.     From  a  patient  in  the  Episcopal  Hospital. 

Pericolitis  Sinistra. — When  the  sigmoid  is  affected  the  cause  almost 
always  is  infiammation  of  one  or  more  of  the  diverticula  so  commonly 
found  there,  and  the  pathological  changes  are  somewhat  different 
from  those  encountered  about  the  cecum  and  ascenrling  colon.  The 
classification  I  suggested  in  1907  includes:  (1)  Sigmoiditis,  an  inflam- 
matory hyperplasia  of  the  walls  of  the  sigmoid,  converting  it  into  a 
rigid  tube,  and  usually  causing  a  certain  amount  of  obstruction.  This 
is  comparatively  rare.  It  may  be  caused  by  inflammation  of  a  diver- 
ticulum buried  in  the  intestinal  wall  or  in  &n  epiploic  appendage. 
(2)  Perisigmoiditis,  which  usually  is  the  result  of  inflammation  of  a 
diverticulum  projecting  into  the  free  peritoneal  cavity.  This  may  or 
may  not  lead  to  perforation  or  abscess  formation.  The  symptoms 
resemble  those  of  appendicitis,  except  that  they  occur  on  the  left  side, 
and  the  treatment  is  the  same,  viz.,  excision  of  the  diverticulum  and 
drainage  of  the  abscess,  or  in  rare  cases  resection  of  the  diseased  portion 
of  the  sigmoid,  especially  if  there  is  any  suspicion  of  malignancy, 
."sigmoid  diverticulitis  has  been  particularly  studied  by  Mayo  (1907) 


898 


SURGERY   OF   THE  GASTRO^IXTESTIXAL    TRACT 


and  by  Brewer  (1907).  (3)  Mesosigmoiditis:  This  again  is  most  often 
due  to  inflammation  of  a  diverticulum  lying  within  the  layers  of  the 
meso-sigmoid,  or  to  an  ulcer  in  the  sigmoid.  Sometimes  a  distinct 
tumor  is  formed  by  the  secondarily  enlargeri  lymph  nodes  (Fig.  873); 
and  sometimes  tiie  meso-sigmoid  becomes  contracted  and  distorted, 
causing  secomlary  uli-tructive  symptoms  (Ries,  1907). 

Cecum  Mobile. — An  unduly  mov- 
able cecum  may  l>e  the  cause  of 
many  of  the  symptoms  just  de- 
scribed, according  to  Wilms  (190Sj. 
This  condition  may  be  associated 
with  Lane's  kink  or  with  Jackson's 
membrane,  constricting  the  ascend- 
ing cdldii  or  hepatic'  flexure,  and 
is  to  be  treated  by  suspension  of 
the  cecum  by  suture  to  the  parietal 
peritoneum  after  removal  of  the 
appendix  and  any  adventitious 
membrane  present. 


Flu.  s7-i.  —  P.jLi.^v..-^,^!  u'-.A'Auou: 
complaints  of  backache  and  invalidism 
for  years.     Episcopal  Hospital. 


Fig.  S7.3. — Meso-sigmoiditis,  in  a  child  of 
seven  years.  Recover}'  after  exploratory 
laparotomy.     Children's  Hospital. 


f"iij.  ^7o. — Saruf-  patit-iit  a^r  Fitr.  ^74. 
All  symptoms  relieved  by  wearing 
suitable  belt. 


Visceroptosis. — Glenard,  in  1885,  drew  attention  to  general  visceral 
prolapse,  involving  the  hollow  viscera,  usually  the  right  kidney,  and 
sometimes  the  liver  and  spleen  as  well.  The  deformity  is  more  common 
in  women,  and  may  or  may  not  be  associated  with  penduhus  abdomen. 
It  is  recognized  now  as  not  very  rare  in  children,  and  is  often  held 


VllIiUMC   IXTJ'JSTIXAL  ,STAS1S 


SO!) 


r('sj)()iisil)l('  tor  cliroiiic  constipation.  Oastroptosis,  already  inontioiicd 
at  p.  S71.  usually  is  a  part  of  ji;(MU'ral  visceral  prolapse.  In  cases  of 
pendulous  ahdonicn  synii)toinsof  sacro- 
iliac relaxation  (p.  i')'.\!'))  may  arise,  and 
much  comfort  often  he  derived  from 
the  use  of  an  ahdominal  helt  (V\^.  S75) 
or  properly  fittinii;  corset,  thouf^h  skia- 
graphs made  (after  the  use  of  bismuth 
jijruel  hy  mouth  or  enema)  before  and 
after  the  aj)i)lication  of  such  a  su])i)ort 
do  not  show  any  noticeable  chanj^e  in 
the  position  of  the  hollow  viscera. 
Relief  probably  is  secured  by  over- 
cominij  static  strain  in  the  pelvic  joints 
and  lumbar  spine. 

Chronic  Constipation,  which  often  is 
due  to  some  mechanical  factor,  such  as 
visceroptosis  or  one  of  the  types  of 
pericolitis  above  described,  is  treated 
by  Lane  by  means  of  exclusion  of  the 
colon  by  ileo-sigmoidostomy.^  In 
some  cases  the  entire  colon  is  excised 
at  the  same  time  or  subsequently, 
(^odman  warns  against  accepting  with- 
out question  the  evidence  of  skia- 
graphs made  after  the  ingestion  of 
bismuth  gruel  as  indicating  true  ob- 
structive kinks  in  the  large  intestine, 
since  it  has  been  found  by  Hertz  that 
fluoroscopic  examination  demonstrates 
no  obstruction  to  the  onward  course 
of  the  intestinal  contents  even  when 

the  kinks  appear  very  pronounced.  In  most  cases  of  chronic  constijja- 
tion  the  delay  occurs  in  the  pelvic  colon,  and  not  at  the  hepatic  or 
splenic  flexures  where  kinks  are  most  apparent. 

1  According  to  Lane's  theory  most  human  ailments  are  due  to  "chronic  intestinal 
stasis:"  the  primary  condition  is  some  obstruction  in  the  descending  colon  or 
sigmoid;  this  results  in  cecal  dilatation,  and  in  attempts  to  overcome  the  obstruc- 
tion adventitious  attachments  are  formed  around  the  cecum  and  lower  ileum  which 
should  be  regarded  as  nature's  efforts  to  fix  the  bowel  in  a  more  effective  position. 
Unfortunately  this  usually  results  in  obstruction  in  the  lower  ileum;  the  weight 
of  the  retained  secretions  in  the  jejuno-ileum  causes  a  kink  at  the  duodeno-jejunal 
juncture,  and  again  in  an  effort  to  overcome  this  nature  produces  adhesions  around 
the  origin  of  the  jejunum  which  may  increase  the  obstruction,  and  by  leading  to 
dilatation  of  the  duodenum  may  be  responsible  for  the  development  of  duodenal 
ulcer.  Gastro-enterostomy  Lane  holds  is  effective  merely  because  suspension  of 
the  first  jejunal  loop  to  the  stomach  relieves  obstruction  at  the  duodeno-jejunal 
juncture;  the  gastro-jejunal  anastomosis  is  of  no  use  whatever.  The  only  rational 
treatment  for  all  these  conditions  he  contends  is  section  of  the  lower  ileum  and 
union  of  its  proximal  end  with  the  sigmoid  below  the  last  obstruction.  In  this 
way  he  claims  to  have  cured  such  diverse  lesions  as  exophthalmic  goitre,  tuber- 
culosis of  the  hip,  trifacial  neuralgia,  etc.,  all  of  which  he  attributes  to  a  primary 
auto-intoxication  from  chronic  intestinal  stasis. 


Fig.  876.— Congenital  megacolon. 
From  a  patient  under  the  care  of  the 
late  Prof.  Ashhurst  in  the  University 
Ho.spital. 


900  SURGERY   OF   THE   GASTRO  INTESTINAL    TRACT 

Congenital  Megacolon. — This  is  believed  by  most  patholojijists  to 
be  really  of  congenital  origin,  as  indicated  by  the  name  selected  for 
it  by  Hirschs])rnng  in  lcSS().  It  is  also  known  as  IIir,sclifiprnn(fs 
Disease.  Whether  or  not  there  is  always  a  mechanical  obstruction, 
or  whether  the  dilatation  of  the  colon  is  of  neuropathic  origin,  are 
questions  still  in  dispute.  The  sigmoid  flexure  is  usually,  and  the 
entire  colon  often,  involvecl;  while  the  rectum  and  the  small  intestine 
almost  always  escape  the  dilatation.  Most  patients  come  under 
obserxation  lietween  the  ages  of  two  and  ten  years.  Obstinate  con- 
stipation exists  from  very  early  life;  the  abdomen  becomes  immensely 
distended  (Fig.  87(i) ;  the  colon  is  packed  with  feces ;  tympany  may  be 
extreme  at  times;  and  the  usual  symptoms  of  fecal  impaction  are 
present.  The  general  health  is  impaired,  and  the  child's  growth  may 
be  arrested. 

Treatment. — Treatment  in  mild  cases,  and  especially  in  \ery  young 
patients,  should  be  palliative,  as  for  any  ordinary  case  of  chronic 
constipation.  In  others,  operative  treatment,  which  ofi'ers  the  only 
hope  of  permanent  cure,  should  not  be  delayed  too  long.  Cecostom>' 
I  believe  is  the  operation  of  choice;  this  is  to  be  followed  "by  free 
irrigations  of  the  bowel  through  the  fistula,  and  when  the  colon  has 
been  well  cleansed  and  the  patient's  health  is  improved,  the  entire 
portion  of  bowel  afl'ected  is  to  be  resected. 

Tumors  of  the  Sigmoid  and  Pelvic  Colon  are  considered  in  con- 
nection with  those  of  the  rectum  (p.  913). 

SURGERY  OF  THE  RECTUM  AND  ANUS. 

Examination  of  the  Anus  and  Rectum. — Digital  examination  may 
be  employed  with  the  patient  on  his  back  with  thighs  flexed,  or  stand- 
ing in  a  stooping  posture.  The  gloved  finger,  well  lul)ricated  with  green 
soap,  is  gently  insinuated  until  both  sphincters  are  passed,  when  its 
tip  will  be  in  the  rectum,  which  normally  contains  no  feces.  In  men 
the  prostate  and  seminal  vesicles  can  be  felt  beneath  the  anterior 
rectal  wall,  and  in  women  the  cervix  of  the  uterus  usually  can  be  felt. 
Most  pathological  changes  occur  in  or  near  the  anal  canal,  and  they 
often  are  overlooked  because  the  examiner  expects  to  find  them  too 
high  in  the  rectum.  If  visual  inspection  is  desired,  it  is  necessary  to 
dilate  the  sphincter;  this  is  best  done  under  a  general  anesthetic.  First 
one  index  finger  then  the  other  is  introduced,  and  by  gradually  sepa- 
rating them  in  various  diameters,  the  sphincter  is  dilated.  Usually  it 
is  desirable  to  dilate  it  until  the  finger  comes  into  contact  with  the 
tuberosity  of  the  ischium  on  each  side.  The  mere  fact  of  dilatation 
renders  the  anal  canal  visible,  but  to  inspect  the  rectum  high  up,  a 
speculum  (proctoscope)  is  necessary.  Fig.  877  shows  some  convenient 
types.  The  patient  should  lie  on  his  back,  with  thighs  well  flexed  on 
the  pelvis.  The  speculum  is  introduced  gently,  with  the  obturator  in 
place,  and  when  introduced  to  its  full  depth  the  obturator  is  removed, 
any  fecal  matter  or  mucus  is  sponged  away,  and  as  the  speculum  is 


sih'chun   oi'  rill-:  i/hci'im  wn  wis 


!)()1 


slowly  wit  lidraw  II  llic  iiiiitosa  which  |)r(»hii),s('>  into  its  end  is  carc- 
l'iill\  iiis|)(Mt(Ml  Tor  iihcrs.  (hhitcd  hemorrhoidal  veins,  orifices  of 
listuhe,  etc.  A  siumoidoscopo  is  simihir  to  a  |)roctoscoi)e,  l)iit  much 
JoMjjor  Ot*  to  II  inches):  it  is  inserted  with  j^reat  care  until  its  tip  K^'ts 
well  beyond  the  hollow  of  the  sacrum,  and  the  bowel  is  examined 
(by  lijiht  reflected  from  a  head  mirror,  or  preferably  l)y  means  of 
an  incandescent  bull)  at  the  point  of  the  instnnnent)  from  above 
downward,  as  the  instrument  is  withdraw  ii.  In  most  cases  the  instru- 
ment does  not  really  enter  the  siii;nioid,  but  the  entire  rectal  canal 
is  readily  seen,  esi)ecially  if  the  i)elvis  is  rais(>d  so  that  the  rectum 
balloons. 


Fig.  877. — Two  forms  of  proctoscope,  and  a  sijiimoidoscope. 

Congenital  Malformations. — These  are  due  to  failure  of  proper 
union  between  the  primitive  proctodeum  and  the  rectum  (Figs.  878, 
879,  and  880).  The  most  important  classification  is  into  those  infants 
with  absolute  occlusion  of  the  rectal  canal,  and  those  in  whom  there 
exists  some  form  of  fistulous  exit  for  the  meconium.  In  these  latter 
cases  the  rectum  may  empty  into  the  urethra  or  the  bladder,  or  in 
the  female  into  the  vagina.  In  all  except  the  last  mentioned  variety 
the  condition  usually  is  recognized  at  birth,  or  within  a  few  days,  and 
demands  immediate  operation.  When  the  opening  is  into  the  vagina 
no  obstruction  may  occur,  and  the  malformation  may  pass  unnoticed 
until  adult  life. 

In  any  case  the  proctodeum  may  be  present,  as  a  dimple  or  shallow- 
sinus  at  the  normal  site  of  the  anus,  the  occlusion  being  above;  or  there 
may  l^e  no  e\idence  of  an  anus.  The  most  serious  cases  are  those  in 
which  the  proctodeum  is  present  and  the  occlusion  so  high  in  the 
rectum  or  sigmoid  that  it  cannot  be  recognized  from  below,  but  is 
only  inferred  when  symptoms  of  obstruction  have  been  present  for  a 
number  of  da\s.  In  such  cases  I  believe  it  is  safer  to  open  the  cecum 
than  the  sigmoid,  since  the  obstruction  may  be  in  the  latter. 


902 


SURGERY  OF   THE  GASTRO-INTESriNAL   TRACT 


I  demonstrated  in  1907  that  there  are  exceedingly  few  of  these 
cases  in  wliich  the  l)owel  cannot  be  reached  by  a  perineal  operation; 
and  as  the  mortality  of  this  operation  is  very  much  less  than  that  of 
iliac  colostomy  (Littre's  operation,  p.  890)  which  is  the  usual  sub- 
stitute, it  cannot  be  too  strongly  emphasized  that  perineal  proctoplasty 
almost  always  may  l)e  successfully  accomplished.  An  antero-posterior 
incision  is  made  in  the  perineum,  over  the  normal  site  of  the  anus, 


Fig.    878. — Congenitally    imperforate 
rectum,  proctodeum  absent. 


Fig.  879. — Contrenitally    imperforate 
rectum,  proctodeum  present. 


Fig.  880. — Congenitally  imperforate  rectum,  the  bowel  opening  into  the  urinary 

tract. 


from  the  base  of  the  scrotum  to  the  coccyx,  and  this  is  deepened, 
keeping  in  the  metlian  line  and  following  the  curve  of  the  sacrum, 
until  the  rectal  pouch  is  found.  (I  may  go  further,  and  advise,  with 
Stromeyer,  even  if  the  rectum  cannot  be  found  from  below,  that  the 
peritoneal  cavity  be  opened  through  the  perineum  and  any  distended 
loop  of  bowel  found.)  When  the  bowel  is  found,  it  is  opened,  and  its 
margins  are  drawn  down  and  sutured  to  the  skin.    In  newborn  infants 


IS(  ino-liFA'TA  L   A  liHCEHS 


903 


tlic  |)r()iii(»iit()r\  of  the  siicnmi  is  only  '.\  to  ')  cm.  (!',  to  2  inches) 
(listiiiit  t'roin  tlic  amis,  ami  I  liaxc  on  several  occasions  carried  the 
dissection  as  far  as  tiiis  and  succeeded  in  finding  the  rectum;  and  none 
of  the  patients  so  treated  (one  of  whom  was  two  weeks  old  when 
brought  for  oi)eration)  has  died.  On  the  other  hand,  the  only  patient 
on  whom  I  ha\e  been  forced  to  do  iliac  colotomy  (cecostomy)  died 
of  inanition;  this  was  a  case  in  which  no  obstruction  could  be  felt  from 
below,  and  where  the  autopsy  showed  there  was  agenesis  of  a  portion 
of  the  sigmoid,  producing  obstruction.  In  cases  where  the  bowel 
opens  into  the  bladder  or  urethra  it  almost  surely  will  be  j)ossible  to 
reach  the  rectal  ampulla  from  below,  if  nothing  more  radical  can  be 
done  the  surgeon  can  at  least  establish  a  common  perineal  opening 
for  feces  and  urine,  thus  preventing  temporarily  ascending  infection 
of  the  urinary  tract.  When  the  child  is  older  a  more  radical  opera- 
tion may  be  attempted. 

When  the  bowel  opens  into  the  vagina,  it  is  best  to  dissect  the 
rectum  free,  transplant  the  fistulous  opening  in  it  to  the  normal  site 
of  the  anus,  and  repair  the  vaginal  opening  (Uizzoli,  1856). 

Abscess  Around  the  Rectum  and  Anus. — This  is  a  frequent  affection, 
and  the  abscess  may  occur  in  various  situations  (Fig.  SSI):  (1)  .S'///;- 
iegumental  or  perianal,  which 
is  between  the  skin  and  the 
external  sphincter;  (2)  ischio- 
redaJ,  the  most  frequent  of 
all,  which  occupies  the  ischio- 
rectal fossa,  between  the  skin 
and  the  levator  ani  muscle; 
(3)  submucous  between  the 
mucous  membrane  of  the 
rectum  and  the  internal 
sphincter;  (4)  jjehi-rectal, 
which  develops  above  the 
levator  ani  muscle,  just  out- 
side the  muscular  w^all  of  the 
bowel;  and  (5)  retrorectal, 
which  is  similar  to  the  last  named,  except  that  it  develops  in 
the  hollow  of  the  sacrum.  As  will  be  seen  by  reference  to  the 
diagram  all  of  these  abscesses  have  their  origin  in  the  region  of  the 
anus  between  the  sphincters,  and  almost  always  they  are  the  result 
of  slight  trauma,  from  hardened  feces,  perhaps  combined  with  exposure 
to  wet  and  cold.  The  patient  complains  of  burning  and  scalding  in 
the  rectum  and  great  pain  on  defecation;  it  pains  him  to  sit  down; 
and  he  may  have  retention  of  urine. 

Ischio-rectal  Abscess  is  most  frequently  seen.  Examination  in 
the  earliest  stages  shows  merely  a  sense  of  resistance  close  to  the 
sphincter  ani,  with  extreme  tenderness.  Later  the  whole  ischio-rectal 
region  on  one  side  may  be  tumefied,  red,  edematous,  and  pitting 
on  pressure.    Occasionally  the  abscess  bursts  spontaneously  into  the 


Fig.  881. — -Perianal  abscesses.     (See  text.) 


904 


SlIRdKRY   OF   TIIK   CASTRO  IM'MSl'INAL    TRACT 


rectum  (l)etween  the  external  and  internal  s])hincters)  or  on  the 
surface;  hut  usually  it  is  so  painful  that  surgical  treatment  is  sought 
quite  early.  Treatment  consists  in  opening  the  abscess  by  an  incision 
radiating  from  the  anus  in  the  case  of  very  small  abscess;  or  by  an 
anteroposterior  incision  if  the  abscess  is  large.  The  incision  must  be 
much  longer  than  seems  necessary,  since  it  contracts  \'ery  rapidly 
when  the  pus  is  discharged.  The  cavity  is  drained  by  a  wick  of  gauze, 
and  is  allowed  to  heal  by  granulation.  Great  care  in  dressing  is 
requisite  to  prevent  damming  up  of  pus.  The  affection  is  not  usually 
a  serious  one,  but  I  have  seen  a  few  fatal  cases  in  alcoholics  and  patients 
otherwise  unable  to  withstand  infection.  The  siinis  may  be  very  slow 
in  healing,  and  fistula  in  ano  is  a  frequent  result,  especially  if  rupture 
into  the  bowel  takes  place. 

The  other  forms  of  abscess  mentioned  require  the  same  treatment, 
but  in  those  which  lie  above  the  external  sphincter  (submucous)  it 
is  desirable  to  divide  this  also,  as  in  fi.s-tula  in  ano,  to  secure  better 
drainage.  A  pelvi-rectal  abscess  should  be  opened  by  an  incision  in 
the  ischio-rectal  fossa,  after  which  the  abscess  is  freely  opened  and 
drained  by  puncturing  the  levator  ani  and  then  dilating  it  by 
Hilton's  method  (p.  51). 

Fistula  in  Ano. — The  most  frecpient  cause  of  a  fistula  a})out  the 
anus  is  ischio-rectal  abscess. 

The  fistula  may  have  two  openings,  one  on  the  skin  surface  (usually 
over  the  ischio-rectal  fossa)  and  the  other  on  the  mucous  surface 
(usually  between  the  external  and  internal  sphincters) ;  this  is  known 
as  a  complete  fistula.  Only  one  opening  may  exist,  and  this  may  be 
on  the  skin  surface  (blind  external  fistula),  or  on  the  mucous  surface 
(blind  internal  fistnla).  Sometimes  there  are  two  or  more  skin  openings 
to  the  same  fistula,  which  may  then  resemble  a  horseshoe  in  form. 
Occasionally  several  independent  fistula^  exist. 


Fig.  882. — FistuliB  in  ano:  1,  complete  fistula  (usual  form);  2,  blind  external 
fistula  (usual  form);  .3,  blind  internal  fistula;  4,  blind  external  fistula  with  suppurat- 
ing tracts;  5,  complete  fistula  entering  the  bowel  above  the  internal  sphincter. 


Symptoms  and  Diagnosis. — The  patient  complains  of  a  discharge  of 
pus,  or  an  irritation  of  the  skin  around  the  anus.  The  external  orifice 
of  the  fistula  usually  is  easily  detected  when  the  l)uttocks  are  separated; 
it  may  be  marked  by  a  granulation  or  a  tab  of  skin.    The  internal  orifice 


FIsriLA    AM)    /'ISSIh'h'   or    Til/':    AXIS  «)().") 

soinct  iin('>  ('ill I  he  IVIt  l)y  :i  liiijicr  in  I  lie  rcct  iiiii  ;i>  ;iii  iiidiiratt-d  .sj;()l,  or 
it  may  l)c  made  \  isihlc  hy  means  of  a  rectal  speeulnrn.  The  suj)j)urat- 
iiii,^  tract  which  connects  the  two  may  he  \ery  dexioiis.  IF  it  is  desiretl 
to  |)rohe  th(>  fistuhi  without  K'^''"K  ''  K^'iieral  anesthetic,  the  finder 
shouM  he  intro(hiced  into  tlie  rectum  hefore  the  probe  is  passed  into 
the  simis.  I^\-er.\-  fistuhi  around  the  anus  is  not  a  fistuhi  in  aito;  it 
max  he  a  ])ih)-ni(hd  sinus  (p.  2(')())  or  the  oi)eiiinfJj  of  a  cold  abscess  in 
connection  with  (hsease  of  the  jx'Ivic  bones  or  \'ertel)ral  column;  or, 
more  prol)ably,  a  fistula  resulting-  from  a  jjcri-urethral  ai)scess  (j).  1027). 

Treatment.  If  the  fistula  is  of  very  recent  formation,  palliative 
treatment  may  l)e  em])lo\'e<i.  ( "auterization  with  sil\er  nitrate  or 
chloride  of  zinc,  or  injections  of  bismuth  paste  sometimes  })ring  tem- 
porary relief,  but  permanent  cure  without  oj>erati<)n  is  very  rare. 
The  classical  operation  consists  in  laying  open  the  fistula  from  one 
orifice  to  the  other,  by  division  of  the  external  anal  sphincter.  A 
grooved  director  is  passed  into  the  external  opening  of  the  fistula,  is 
caught  l)y  a  finger  as  it  emerges  in  the  anal  canal  or  rectum,  and  its 
point  is  bent  down  and  brought  out  of  the  anus,  which  is  then  slit  tip 
on  the  director  as  guide.  In  the  case  of  external  blind  fi.stuhe  the 
director  is  passed  into  the  sinus  and  is  made  to  perforate  the  rectal 
mucous  membrane  where  this  seems  thinnest.  A  blind  internal  fisttila 
may  be  opened  up  in  similar  manner  after  exposing  its  internal  orifice. 
When  the  fistula  is  once  laid  open,  the  cicatricial  tissue  lining  it  is 
cut  or  scraped  away,  and  the  raw  surface  is  packed  and  allowed  to 
heal  by  granulation.  The  sphincter  should  be  cut  transversely,  not 
obliquely  to  its  fibres,  and  in  not  more  than  one  place  at  the  same 
operation,  even  if  several  fistulae  exist,  for  fear  of  producing  inconti- 
nence of  feces. 

Of  late  years  many  surgeons  ha\e  had  much  success  in  curing 
fi.stula  in  ano  by  formal  excision  of  the  tract  followed  by  immediate 
closure  by  buried  absorbable  sutures;  but  the  practice  is  not  yet  very 
common. 

Some  of  these  fistula^  are  tuberculous  in  nature;  usually  they  develop 
very  insidiously,  and  usually  a  tuberculous  focus  exists  elsewhere  in 
the  body.  Unless  the  other  lesions  are  very  far  advanced,  tuberculous 
fistuhe  should  be  treated  by  excision  and  suture,  as  those  of  simple 
infiammatory  nature.  Scraping  and  leaving  the  wound  open  is  apt 
to  result  in  recurrence. 

Fissure  of  the  Anus. — If  a  lump  of  hardened  feces  tears  down  one 
of  the  anal  vahes,  the  trauma  is  very  apt  to  result  in  an  indolent  ulcer, 
lying  in  the  grasp  of  the  external  sphincter.  The  ulcer  is  placed 
longitudinally  in  the  anal  canal,  almost  always  at  its  posterior  mid- 
portion,  and  usually  extends  on  to  the  skin  surface.  Almost  unbearable 
burning  pain  at  the  anus,  after  every  act  of  defecation,  and  lasting 
for  an  hour  or  more,  is  a  highly  characteristic  symptom;  and  inspection 
of  the  anus  confirms  the  diagnosis.  Digital  examination  of  the  anal 
canal  should  not  be  made  until  the  surgeon  is  ready  to  treat  the  lesion. 
Very  occasionally  a  recently  formed  fissure  can  be  made  to  heal  bv 


906  SURGERY  OF   THE  (lASTRO-1  NTESTINAL   TRACT 

cauterization,  application  of  a  stimulating  ointment,  and  scrupulous 
cleanliness;  but  in  most  cases  operation  is  required.  This  consists 
in  division  of  the  sphincter  through  the  base  of  the  ulcer,  under  a 
general  anesthetic.    Healing  is  then  prompt  under  ordinary  dressings. 

Hemorrhoids  or  Piles. — A  varicose  condition  of  the  rectal  veins  is 
a  ver}'  frequent  afi'ection.  The  inferior  hemorrhoidal  veins  drain  into 
the  internal  pudic;  the  middle  hemorrhoidals  into  the  internal  iliac  or 
one  of  its  branches;  while  the  superior  hemorrhoidals  are  tributaries 
of  the  portal  system  tlirough  the  inferior  mesenteric  vein.  These 
veins  lie  beneath  the  mucosa  in  loose  areolar  tissue,  possess  no  valves, 
and  are  therefore  especially  subject  to  the  effects  of  gravity;  there  are 
free  anastomoses  between  the  superior  and  the  middle  and  inferior 
hemorrhoidal  veins,  so  that  dilatation  of  one  set  is  quickly  succeeded 
by  dilatation  of  the  others.  In  addition  to  the  eflfect  of  gravity,  which 
is  always  acting,  these  veins  are  liable  to  distention  from  the  pressure 
of  the  contents  of  the  rectum  and  sigmoid,  from  disturbances  in  the 
portal  circulation  (which  occur  during  every  period  of  digestion,  and 
which  pathological  states  frequently  render  constant),  and  from 
pressure  on  the  pelvic  veins  in  cases  of  ovarian,  uterine,  or  prostatic 
disease.  Straining  in  urination  (as  from  stricture)  as  well  as  that 
due  to  chronic  constipation,  is  a  frequent  cause. 

Hemorrhoids  are  classed  as  internal  (which  are  covered  with  mucous 
membrane)  and  external  (covered  by  skin),  or  as  inter o-external, 
according  to  their  relation  to  the  sphincters.  Hemorrhoids  are  further 
classed  as  bleeding,  inflamed,  thrombosed,  etc.,  terms  which  sufficiently 
explain  themselves. 

The  affection  is  commonest  in  adults,  but  is  not  very  rare  in  the 
young  and  the  aged.  External  piles  appear  as  protrusions  of  small 
size,  close  around  the  anus;  they  are  covered  with  normal  skin,  unless 
inflamed,  when  they  become  purplish  or  red,  swollen  and  very  tender. 
Suppuration  may  occur,  and  clotting  of  the  contained  blood  is  not 
very  unusual;  in  this  w^ay  a  phlebolith  may  develop.  The  skin  around 
the  anus  may  become  much  macerated,  and  at  first  glance  the  condition 
may  be  mistaken  for  mucous  patches;  but  the  latter  usually  are  not  the 
only  signs  of  syphilis  present,  and  frequently  occur  elsewhere  as  well 
as  around  the  anus.  Internal  piles  are  arranged  in  a  circle  just  within 
the  sphincters;  occasionally  some  are  found  higher  up.  They  are 
bluish-black  protrusions  beneath  the  mucous  membrane,  and  are 
easily  compressible  unless  partly  organized  or  thrombosed  from 
repeated  attacks  of  inflammation.  The  piles  become  worse  when  the 
paaent  is  constipated,  and  may  protrude  only  when  he  strains  at 
stool  or  may  come  down  on  the  slightest  effort  (Fig.  883),  leading 
eventually  to  prolapse  of  the  rectum.  There  is  a  sense  of  fulness  and 
discomfort  in  the  rectum  almost  all  the  time,  and  during  a  "fit  of  the 
piles,"  when  these  structures  become  inflamed,  the  pain  may  be 
almost  unendurable  and  may  radiate  in  various  directions.  Free 
bleeding  from  the  dilated  veins  usually  brings  relief,  and  is  a  rather 
frequent  occurrence,  especially  at  the  end  of  a  bowel  movement.    The 


HEMOh'h'lloiDS 


907 


l)l()()(l  is  hri^'lit  red,  and  appears  spread  oxer  the  tVcal  masses,  not 
min^ded  with  tlien),  as  is  hlood  wliich  conies  from  hi^dier  up  in  the 
intestinal  tra<'t,  and  which  is  apt  to  l)e  l)rown  and  clotted  before  it  is 
passed. 


Fig.  883. — Internal  hemorrhoids,  protruding  and  bleeding.     Episcopal  Hosi)ital. 

Treatment. — Any  cause  which  can  be  discovered  should  be  removed 
if  possible.  In  mild  cases  it  is  sufficient  to  attend  to  the  state  of  the 
bowels,  procuring  at  least  two  free  and  soft  motions  daily  by  means 
of  dieting  and  mild  laxatives,  such  as  salines  in  the  morning,  senna, 
rhubarb,  etc.  Active  purges  have  little  therapeutic  effect  though  they 
may  be  required  to  unload  the  rectum.  Scrupulous  cleanliness  must 
be  preserved  by  irrigation  or  injections  of  cold  water;  protruding 
piles  should  be  pushed  back  after  defecation;  and  some  astringent 
ointment  (as  one  of  equal  parts  of  gall  and  stramonium  ointment, 
U.  S.  P.)  may  be  applied  to  the  anus.  Should  inflammation  occur, 
the  patient  should  be  confined  to  bed,  with  the  pelvis  slightly  elevated; 
and  an  ice  bag  or  dry  hot  cloths  may  be  applied  locally.  Moist  heat 
should  be  avoided.  Much  relief  may  be  secured  by  the  administration 
of  the  following:  I^ — E.ii.  rhamni  pursh.  fl.,  fgss;  ext.  ergot,  fl.,  f5j; 
exi.  hamamelis  fl.,  f5iss. — M.  S. — -Teaspoonfid  in  water  ihree  or  four 
times  daily.  Sometimes  suppositories  of  opium,  with  acetate  of  lead 
or  tannic  acid,  prove  useful.  If  thrombosis  occurs  and  the  pile  is 
excessively  painful,  it  may  be  punctured  and  the  clot  evacuated. 
Usually  it  is  best  to  postpone  more  formal  operative  treatment  until 
the  inflammation  has  subsided.  Some  surgeons  employ  palliative 
operations,  especially  the  injection  of  carbolic  acid  into  the  base  of 
each  of  the  piles  (one  or  two  at  each  sitting)  which  are  thus  thrombosed 
and  may  eventually  shrivel  up.  I  have  no  experience  with  this  method 
myself,  but  believe  that  as  commonly  employed  it  is  neither  efficient 
nor  entirely  safe.  Wallis  prefers  a  10  per  cent,  solution  of  carbolic 
acid  in  glycerin  and  water;  3  to  8  minims  are  injected  into  the  pile, 
according  to  its  size.    He  found  his  patients  secured  temporary  relief. 

Several  radical  operations  are  in  common  use  for  cases  of  hemor- 
rhoids, the  chief  of  which  are  ligation,  clamp  and  cautery  operation 


9()X     SURGERY   OF   THE  U ASTRO  INTESTINAL   TRACT 

and  excision.  For  the  average  operator  there  is  no  (loiil)t  that  the 
first  of  these  is  the  method  of  ehoiee  both  for  safety  and  for  certainty 
of  enre.  For  internal  liemorrhoids  J  think  it  is  preferabh-  to  cauteriza- 
tion, though  the  latter  is  widely  employed  for  these  as  well  as  for 
external  piles.  Plxcision,  the  most  radical  of  all,  is  a  more  formidable 
operation,  and  though  sufficiently  simj)le  to  a  skilled  operator,  entails 
more  risk  to  the  ])atient. 

Ligation  of  Hemorrhoids. — The  anus  is  dilated  as  described  at  p.  900, 
and  each  pile  mass  is  caught  in  suitable  forceps.  Hemostatic  forceps 
are  not  efficient,  as  they  usually  tear  loose.  The  Allis  forceps  or  a 
special  ring  forceps  may  be  used.  I'nless  all  the  piles  are  clamped 
in  this  way  at  one  time,  there  will  be  danger  of  dislodging  the  ligatures 
already  placed  while  the  remaining  piles  are  being  sought  for.  If  there 
is  any  pile  which  has  a  cutaneous  margin  (intero-external  hemorrhoid) 
a  groove  should  be  cut  around  its  base  through  the  skin  with  scissors; 
this  prevents  the  ligature  from  slipping,  and  by  severing  the  skin 
nerves  reduces  the  discomfort  after  operation.  A  groove  may  be 
cut  also  in  the  mucous  membrane,  all  around  the  base  of  the  pile, 
exposing  its  pedicle,  but  this  is  not  necessary.  Then  a  curved  needle 
carrying  a  long,  stout,  linen  thread  is  made  to  transfix  the  base  of  the 
pile,  in  the  long  axis  of  the  rectum;  the  loop  of  the  thread  is  cut  and 
the  pile  is  ligated  in  two  sections,  the  ligatures  interlocking  and  being 
tied  in  the  groove  already  out.  The  protruding  portion  of  the  hem- 
orrhoid is  then  cut  away  leaving  enough  stump  to  prevent  slipping 
of  the  ligature.  The  ends  of  the  latter  should  be  left  long  until  it  has 
been  ascertained  that  no  bleeding  occurs.  Each  pile  mass  (usually 
there  are  not  more  than  five)  is  treated  in  the  same  way.  Finally  the 
surfaces  of  the  amputated  piles  are  dusted  with  iodoform  powder,  and 
a  sterile  pad  is  applied  to  the  anus  and  held  in  place  by  a  T-bandage. 
Usually  the  bowels  move  spontaneously  by  the  fourth  da}\  If  tJiey 
do  not  they  should  be  opened  by  a  dose  of  castor  oil.  An  enema  should 
not  be  given.  Particular  attention  to  local  cleanliness  and  efficient 
drying  should  be  enforced  for  two  wrecks;  usually  the  patient  may 
leave  bed  in  a  week  or  ten  days  after  operation. 

Clamp  and  Cautery  for  Hemorrhoids. — After  dilating  the  sphincter 
and  grasping  all  the  piles  in  suitable  forceps  as  already  advised  a  special 
pile  clamp  is  applied  to  one  of  the  masses,  in  the  long  axis  of  the 
bowel,  and  is  screwed  so  tight  as  to  crush  the  base  of  the  pile.  The 
protruding  tissue  is  cut  away,  and  the  stump  in  the  grasp  of  the  pile- 
clamp  is  cauterized  with  the  cautery  at  a  dull  (cherry)  red  heat. 
Though  the  pile-clamp  usuall}'  has  its  under  surface  faced  with  ivory, 
to  prevent  radiation  of  the  heat  to  the  surrounding  tissues,  it  is  well 
as  an  additional  safeguard  to  surround  it  with  damp  cloths  while 
the  cautery  is  in  use.  Each  pile  mass  in  turn  is  treated  in  similar 
fashion,  and  subsequent  treatment  is  conducted  as  already  described. 
Excision  of  Hemorrhoids  (Whitehead,  1882). — An  incision  is  made 
in  a  circle  around  the  muco-cutaneous  juncture  of  the  anus,  and 
the  mucous  membrane  including  the  pile-bearing  tissue  is  dissected 


I'h'oLM'SK  OF  riih:  h'j'jci'r.M 


!)(l!) 


upward  with  siiii)s  of  the  scissors  and  <;au/,('  pressure,  until  liealtliy 
unicous  lucuiliraiie  is  reached  on  all  sides,  'i'he  diseased  cufi'  of 
nuicous  uieuihrane  is  then  excised,  and  the  uuicous  ineinhrane  above 
is  united  to  the  skin  below  by  a  continuous  suture  of  chromic  catgut. 
If  properl\  done  there  is  very  little  hemorrhage,  as  the  varicose  veins 
tluMuseh  es  are  not  opened;  and  there  is  little  chance  of  stricture  result- 
ing unless  infectit)n  occurs.  Frecfucntly  the  mucous  membrane  and 
skin  separate  slightly  at  one  or  more  points,  but  this  does  not  occur 
until  granulation  tissue  has  formed. 

Prolapse  of  the  Rectum. — This  develops  as  the  result  of  repeated 
straining  efforts,  as  in  cases  of  hemorrhoids  with  constipation  or  in 
severe  diarrhea  with  rectal  tenesmus,  or  sometimes  as  the  resuit  of 
whooj)ing  cough.  The  loose  mucous  membrane  protrudes  from  the 
anus  at  first  only  during  defecation,  and  may  recede  spontaneously 
when  the  patient  stands  up.  Later,  however,  the  bowel  may  protrude 
at  other  times  and  may  require  to  be  replaced  maiuially.  Occasionally 
reposition  becomes  impossible;  in  such  cases  usually  the  muscular 
wall  of  the  rectum  has  prolapsed  also  (procidentia  recti). 

The  condition  is  most  common  in  young  children,  but  occurs  also 
in  adults,  and  sometimes  during  old  age  when  it  often  seems  to  depend 
on  loss  of  muscular  tone.  In  every  such  case  examination  should  be 
made  to  exclude  the  presence  of  polypus,  stricture,  or  carcinoma 
higher  up  in  the  bowel. 


Fig.  884. — Prolapse  of  rectum.     Children's  Hospital. 

Symptoms. — In  the  ordinary  form  (prolapsus  recti  or  partial  prolapse) 
the  mucous  membrane  of  the  rectum  is  seen  protruding  from  the  anus 
as  a  red  or  purplish  ring.  Usually  the  condition  is  unmistakable 
(Fig.  SS4).  In  c()m|)lete  prolapse  (procidentia)  the  jirotrusion  may  be 
several  inches  in  depth,  and  there  is  a  clearly  recognized  groove  between 
the  mucous  membrane  and  the  anus.  Prolapse  causes  a  sense  of  weight 
and  weakness,  and  often  some  disturbance  of  the  urinary  functions. 
Strangulation  is  rare,  but  is  seen  occasionally  at  the  first  onset  of 
the  prolapse;  when  the  condition  becomes  chronic  the  sphincters 
are  much  relaxed, 


91Q  SURGERY  OF   THE  GASTRO  INTESTINAL   TRACT 

Treatment. — Reduction  usually  may  be  secured  by  moderate  pressure 
with  an  oiled  cloth  or  the  gloved  hand,  while  the  patient  is  lying  prone. 
In  cases  of  strangulation  it  may  be  necessary  to  divide  the  sphincter. 
Recurrence  often  may  be  avoided  by  having  the  bowels  opened  only 
when  the  patient  is  lying  down  flat  on  his  back.  Moreover,  the 
buttocks  should  be  strapped  together  by  adhesive  plaster,  which  is 
removed  only  after  the  bowels  ha\-e  acted,  and  is  at  once  replaced 
when  the  parts  have  been  cleansed.  In  the  case  of  most  children,  in 
whom  the  condition  is  not  of  very  long  standing,  a  cure  results  if  the 
child  is  kept  in  bed  with  proper  regulation  of  diet  and  bowels.  Cod- 
liver  oil  is  valuable  as  a  tonic  for  these  purposes.  If  operation  is 
required  trial  should  first  be  made  of  cauterization  as  in  the  case  of 
hemorrhoids,  clamping,  excising,  and  cauterizing  longitudinal  folds 
of  mucous  membrane  down  to  within  a  half  inch  of  the  anal  margin. 
Or  Whitehead's  operation  may  be  done.  In  Gersiinys  operation 
(1893)  the  anal  canal  is  dissected  free  of  all  attachments  and  is 
twisted  on  itself  until  a  feeling  of  resistance  is  encountered  and 
then  is  sutured  in  its  new  position.^  In  Schomacker's  operation  a 
part  of  each  gluteus  maximus  is  transplanted  around  the  anus,  one 
in  front  and  one  behind;  the  muscular  flaps  are  then  sutured  to  each 
other.  Mummery's  operation  (1910)  consists  in  opening  the  space 
between  the  rectum  and  sacrum  by  a  transverse  incision,  packing 
it  full  of  gauze,  and  allowing  it  to  heal  by  granulation.  The  patient 
should  remain  in  bed  for  a  month.  Mummery  had  complete  success 
with  this  method  in  four  cases  of  severe  procidentia.  After  recovery 
the  posterior  rectal  wall  is  firmly  attached  to  the  hollow  of  the  sacrum 
by  fibrous  tissue.  Sutures  were  used  (instead  of  gauze  packing)  by 
Verneuil  (18S9),  Fowler  (1897),  and  recently  by  Ekehorn  (1909). 
Sigmoidopexy,  or  suspension  of  the  sigmoid  to  the  anterior  abdominal 
wall,  first  employed  in  1889  by  Verneuil,  is  the  most  radical  of  these 
operations  for  procidentia;  but  it  is  wise  to  combine  it  with  a  plastic 
operation  below,  as  recurrence  has  taken  place  in  more  than  half  the 
cases  treated  by  sigmoidopexy  alone  (Pachinio,  1905).  Jeannel's 
operation  included  also  the  formation  of  a  false  anus. 

Proctitis. — Inflammation  of  the  rectum  may  be  traumatic  (from 
impaction  of  feces,  frequent  use  of  enemas,  foreign  bodies,  etc.)  or 
infectious  (dysenteric,  septic,  gonococcic,  etc.).  The  symptoms  are 
a  sense  of  heat,  tenesmus,  frequent,  small,  watery  stools,  often  with 
blood  and  mucus.  There  may  be  considerable  fever  and  much  con- 
stitutional disturbance.  Examination  through  a  speculum  shows 
inflamed  mucous  membrane,  and  frequently  patches  of  lymph  covering 
ulcers  which  bleed  readily  when  touched.  Treatment  involves  removal 
of  the  cause  when  this  is  possible  and  known;  also  cleansing  and  anti- 
septic applications  through  a  speculum.    After  an  ordinary  cleansing 

1  Chetwood  (1902)  employs  a  similar  operation  for  fecal  incontinence;  and  it 
was  for  this  purpose  that  Gersuny's  operation  was  originally  devised,  based  on  his 
experience  (1889)  with  enuresis. 


sTUicrriiKs  (IF  rill':  in-jriM  '.ill 

fii(.'in;i,  ill  srxtTc  cases,  tlu'  patiriil  may  hr  ctlierizcd,  and  a  2  \)vv  ('ciit. 
solution  of  silver  nitrate  swabbed  all  over  the  inflamed  surfaces, 
throuf^li  a  speculum.  Then  the  rectum  is  irrif^ated  with  boric  acid 
solution  (half  saturated),  and  finally  an  injection  is  fjiven  of  a  few 
ounces  of  some  denuilcent  solution  (flaxseed  or  slippery  elm),  contain- 
ing 10  drops  of  laudanum  (Abbe);  this  is  to  be  retained  as  lonj^  as 
possible.  In  mo.st  cases  two  or  three  such  treatments  at  intervals  of  a 
few  days  arrest  the  disease.  But  in  cases  where  colitis  also  exists 
(dy.senteric,  tuberculous),  recurrence  is  the  rule  unless  the  ulcers 
above  can  be  made  to  heal  by  a})propriate  treatment  (p.  89(j). 

Strictures  of  the  Rectum.  These  are  a  frequent  result  of  dysenteric 
ulceration  and  of  trauma  in  childbirth  (Fig.  SI)")).  ^Malignant  ulcera- 
tion causing  obstruction  is  considered  under  the  heading  "^Fumors  of 
tlie  Rectum  (j).  91))).  Inflammatory  changes  in  neighboring  structures 
(vagina,  broad  ligaments  of  uterus,  pelvic  connective  tissue,  prostate, 
etc.)  frequently  extend  to  the  fibrous  tissue  in  the  layers  of  the  rectal 
wall  and  they  may  cause  a  .submucous  or  perirectal  stricture  which  is 
the  same  in  its  effects  as  one  which  arises  in  ulceration  of  the  mucous 
membrane,  since  no  ulceration  of  the  mucous  membrane  which  does 
not  involve  the  fibrous  tissue  can  produce  a  stricture.  Other  causes 
than  those  already  mentioned  are  rare,  though  tuberculous  and 
syphilitic  and  other  specific  ulcerations  and  strictures  do  occur. 
Syphilitic  stricture,  formerly  considered  frecjuent,  is  now  acknowl- 
edged to  be  quite  rare.  When  these  specific  ulcerations  occur  their 
pathology  is  much  the  same  as  that  of  septic  or  traumatic  ulceration, 
since  secondary  infection  from  the  intestinal  contents  is  the  rule. 

Almost  all  strictures  occur  within  three  or  four  inches  of  the  anus; 
those  which  occur  higher,  in  the  sigmoid  or  colon  produce  the  symp- 
toms of  chronic  intestinal  obstruction  (p.  889).  The  stricture  may 
be  single  or  multiple,  marginal  or  annular,  of  large  or  small  calibre. 
The  simple  inflammatory  stricture,  according  to  Tuttle,  usually 
occupies  only  a  portion  of  the  circumference  of  the  bowel,  stands  out 
abruptly  from  the  rectal  wall,  usually  is  close  to  the  anus,  and  has  a 
smooth  surface  covered  with  epithelium.  A  syphilitic  stricture 
presents  a  gradual  funnel-shaped  contraction,  there  is  a  bluish-white 
cicatrix  around  the  edges  of  the  ulcer,  and  the  floor  of  the  ulcer  is 
excavated;  the  edges  of  a  tuberculous  ulceration  always  are  undermined 
and  its  base  is  elevated  (Tuttle).  Secondary  ulceration,  from  fecal 
impaction,  occurs  above  the  stricture,  so  that  when  these  patients 
come  for  treatment  the  rectum  almost  always  is  ulcerated  as  well  as 
strictured,  though  the  ulcers  w^hich  were  the  original  cause  of  the 
stricture  may  have  healed  long  since. 

Symptoms. — These  may  not  develop  for  years  after  the  proctitis 
which  is  the  original  cause  of  the  stricture.  The  patient  may  come 
complaining  of  frequency  of  urination  with  a  sense  of  weight  in  the 
perineum,  and  the  importance  of  thorough  local  examination  cannot 
be  too  often  emphasized.  There  is  a  history  of  the  primary  rectal 
condition,  followed  by  a  latent  period,  and  then  gradually  developing 


1)12     SURGERY  OF   THE  CASTRO-INTESTINAL   TRACT 

but  steadily  increasing-  difficulty  in  obtaining  complete  evacuation  of 
the  rectum.  As  secondary  ulceration  develops,  l)lood  and  mucus  are 
discharged  with  the  stools,  or  frequently  alone,  the  stricture  retaining 
the  fecal  mass  above  it.  The  diagnosis  of  simple  from  malignant 
stricture  is  made  by  observing  the  long  duration  of  the  simple 
stricture  and  the  comparatively  slight  impairment  of  the  general 
health;  and  by  direct  examination  of  the  rectum,  when  the  smooth, 
hard,  but  not  nodular  character  of  the  stricture  determines  it  to  be 
non-malignant.  Malignant  stricture  is  very  rare  before  thirty-five  or 
forty  years  of  age;  its  course  is  rajiid  and  progressive  (two  to  three 
years);  loss  of  flesh  and  strength  appears  early;  the  tumor  is  nodular 
to  the  touch  and  bulges  into  the  lumen  of  the  bowel  as  well  as  causes 
fibrous  thickening  of  its  coats;  and  the  odor  of  the  discharge  is 
gangrenous,  never  simi)ly  fecal  (Tuttle). 

Treatment. — Permanent  cure  cannot  be  hoped  for  from  jxilliafive 
frcdfittent  with  rectal  bougies;  they  are  of  benefit  even  temporarily 
only  when  the  stricture  is  of  recent  formation;  they  must  be  passed 
at  intervals  throughout  the  patient's  life;  and  in  many  cases  serve 
only  to  aggravate  the  patient's  discomfort  by  producing  bleeding 
and  further  ulceration,  even  if  skilfully  and  gently  passed.  An 
ordinary  wax  candle,  molded  by  heat  to  suitable  shape,  makes  as 
good  a  bougie  as  any,  provided  the  stricture  is  not  very  small  and 
is  close  to  the  anus.  In  other  cases  it  is  best  to  use  the  hollow  bougie 
of  Wales,  which  is  introduced  through  a  speculum  passed  up  to  the 
face  of  the  stricture,  and  by  means  of  which  irrigation  may  be  practised 
above  the  stricture.  Before  operative  treatmeni  is  undertaken  it  is 
important  to  cleanse  the  bowel  above  the  stricture.  If  this  cannot  be 
accomplished  from  below  (by  repeated  enemas  or  colonic  irrigations 
through  a  Wales's  bougie,  aided  by  the  use  of  olive  oil  or  gentle  saline 
purges  by  mouth),  it  is  necessary  to  flo  colostomy  (sigmoidostomy). 
After  the  entire  fecal  current  has  been  diverted  in  this  mamier,  and 
the  lower  segment  of  the  bowel  thoroughly  evacuated  and  brought 
into  a  healthy  state  by  irrigations,  direct  treatment  of  the  strictures 
may  then  be  attempted.  Posterior  prortotonn/  (\erneuil),  or  incision 
of  the  posterior  rectal  wall,  including  the  sphincters  and  everything 
down  to  the  bone,  is  not  to  l)e  recommended  unless  the  stricture  is 
close  to  the  anus;  but  it  is  a  good  operation  in  cases  where  septic  proc- 
titis accomj)anies  stricture,  as  it  secures  free  drainage  and  relieves 
the  acute  symptoms  though  it  does  not  produce  a  cure.  The  hemor- 
rhage is  not  alarming  and  may  be  controlled  by  packing  gauze 
around  a  large  rectal  tube.  It  is  necessary  to  continue  the  passage  of 
bougies  subsequently  for  an  indefinite  jieriod.  In  the  case  of  a  single 
high  stricture  it  may  be  possible  to  ])erform  .s-igiiioido-procto.stoDii/, 
making  an  anastomosis  by  the  AIurj)hy  button  between  the  sigmoid 
and  the  rectum  below  the  stricture;  the  spur  between  the  strictured 
and  the  anastomotic  opening  may  be  removed  later  by  Dupuytren's 
enterotome.  In  the  worst  cases  of  stricture  formal  excision  of  the 
rerfinii,  as  for  malignant  disease,  is  the  most  satisfactory  treatment. 


rcMoh's  OF  77//<;  hkcti'm  913 

Recto-urinary  and  Recto-genital  Fistulae. — Formerly  these  were 
frequent  results  of  dlHicuIt  ])arturition,  following  the  separation  of 
sloughs  caused  by  pressure  of  tiie  fetal  head  or  by  instruments;  l)ut 
()wiii<^  to  improvements  in  the  obstetric  art  they  are  now  comparatively 
rare.  Occasionally  they  result  from  operative  injury,  or  from  the 
rupture  of  an  abscess  iuto  both  the  intestinal  and  genito-urinary  tract, 
or  as  the  result  of  specific  or  malignant  ulceration.  The  fistula  may 
connect  the  intestinal  tract  with  the  bladder  or  urethra  (redo-vesical 
and  rcdo-urcthral  fiMidw)  or  with  the  vagina  (recto-vaginal),  rarely  the 
uterus  {recto-uterine  fiduJa) .  Vesico-vaginal  and  vcsico-uterine  fistula 
are  results  of  similar  causes  and  require  similar  treatment,  though 
the  intestinal  tract  is  not  involved.  The  diagnosis  is  made  by  obser\'ing 
the  discharge  of  urine  or  feces  (sometimes  only  of  flatus)  through  an 
abnormal  channel,  and  by  direct  examination  with  sound  or  endoscopic 
instrument  (cystoscope,  proctoscope)  in  the  bladder  or  rectum.  The 
only  satisfactory  treatment  is  by  operation,  which  consists  essentially 
in  dissecting  up  the  borders  of  the  fistula  and  closing  the  opening  in 
the  wall  of  each  viscus  invohed,  by  means  of  separate  sutures.  In 
the  rare  cases  of  recto-uterine  or  vesico-uterine  fistulse  hysterectomy 
may  be  necessary  (Chapter  XXIX). 

Tumors  of  the  Rectum  and  Sigmoid. — Benign  tumors  are  com- 
paratively rare.  Adenoma  is  the  least  unusual.  It  occurs  most  often 
in  children  in  the  form  of  redal  polypus,  and  presents  symptoms 
similar  to  those  of  hemorrhoids,  for  which  or  for  prolapsus  it  is  often 
mistaken,  l^sually  when  the  child  strains  the  polypus  comes  down  in 
reach  of  the  examining  finger,  or  it  may  prolapse  through  the  anus. 
Treatment  consists  in  excision  after  transfixion  and  ligation  of  its 
base.  In  adults  adenoma  and  papilloma  are  quite  rare  growths,  and 
usually  are  pre-carcinomatous  in  nature.  The  tumor  is  rather  soft, 
seldom  is  ulcerated,  and  is  freely  movable  on  the  underlying  rectal 
wall.  It  should  be  freely  excised.  In  the  disease  known  as  multiple 
adenoma  the  entire  colon  may  be  invaded  by  small  polypoid  growths, 
though  usually  the  rectum  is  the  part  most  involved.  The  symptoms 
are  persistent  bloody  diarrhea,  with  tenesmus,  and  gradual  loss  of 
flesh  and  strength.  If  removal  of  the  numerous  rectal  growths  is 
followed  by  their  persistent  recurrence,  or  if  there  is  a  suspicion  of 
malignancy  excision  of  the  rectum  should  be  done;  or  if  the  entire 
colon  is  diseased  a  false  anus  may  be  established  in  the  cecum. 

Carcinoma. — Carcinoma  is  the  most  frequent  tumor  of  the  rectum. 
It  occurs  (1)  at  the  atius  (squamous-celled  carcinoma),  which  is  rare; 
(2)  just  above  the  sphincters  (adeno-carcinoma,  often  encephaloid), 
which  is  not  unusual;  or  (3)  above  the  reach  of  the  examining  finger 
in  the  upper  rectum  or  pelvic  colon,  at  the  level  of  the  promontory  of 
the  sacrum  (adeno-carcinoma,  often  scirrhus);  in  this  latter  situation 
about  two-thirds  of  rectal  cancers  are  found.  The  rectum  frequently 
is  invaded  by  carcinoma  originating  elsewhere  (prostate,  cervix  uteri). 
Anal  carcinoma  causes  secondary  invasion  of  the  inguinal  lymphatics, 
and  clinically  resembles  epithelioma  of  the  lower  lip.  True  rectal 
58 


014  SURGERY  OF   THE  GASTRO-IXTESTIXAL   TRACT 

carcinoma  extends  in  the  submucous  tissues  of  the  rectal  wall  rather 
than  directly  through  it  to  neighboring  structures;  and  invades  the 
lymph  nodes  in  the  hollow  of  the  sacrum,  but  seldom  higher  than  the 
promontory  of  the  sacrum.  Except  in  the  more  highly  malignant 
forms,  death  is  more  apt  to  occur  from  intestinal  obstruction  than 
from  local  extension  or  metastasis. 

Symptoms. — The  symptoms  are  hemorrhage  (especially  in  younger 
patients),  alternating  diarrhea  and  constipation,  and  eventually  loss 
of  weight  and  foul  discharge  with  highly  characteristic  odor.  These 
symptoms,  however,  may  not  appear  for  months  after  the  development 
of  the  tumor,  particularly  if  the  latter  is  high  in  the  rectum.  Often 
the  growth  is  found  absolutely  inoperable  when  no  symptoms  of  note 
have  ever  existed. 

Diagnosis. — Diagnosis  is  not  difficult  at  the  stage  when  most 
patients  consult  a  surgeon.  The  tumor  is  irregular  in  outline,  nodular, 
with  raised  margins  and  ulcerated  centre;  and  it  is  fixed  to  the  bowel 
wall  if  not  to  the  surrounding  structures.  If  any  doubt  exists,  a  piece 
should  1)6  excised  from  the  base,  for  microscopical  study.  If  the 
growth  is  too  high  to  be  accessible  for  diagnosis  from  below,  lapar- 
otomy should  be  done. 

Treatment. — The  first  question  to  decide  is  whether  or  not  radical 
operation  can  be  done,  and,  if  this  is  impossible,  whether  the  establish- 
ment of  a  false  anus  will  promote  the  patient's  comfort.  The  (/rowth 
may  he  considered  inoperable  (1)  when  the  patient's  condition  forbids 
an  operation  with  a  mortality  varying  from  10  to  50  per  cent.;  (2) 
when  the  growth  is  found  to  be  fixed  even  when  examined  under 
anesthesia;  or  (3)  when  distinct  metastases  exist.  In  such  cases 
palliative  treatment  aims  to  reduce  -the  amount  of  fecal  discharge 
and  decrease  its  irritating  qualities  by  attention  to  diet  and  adminis- 
tration of  intestinal  antiseptics;  to  secure  free  evacuation  of  the 
bowels  by  gentle  purging  and  by  enemas  administered  if  possible  by 
a  tube  passed  above  the  growth;  by  local  treatment  of  the  ulcerating 
area  by  irrigation  with  permanganate  or  creolin  solution;  and  finally 
to  keep  the  patient  as  comfortable  as  possible  by  administering  plenty 
of  opium.  In  rare  instances  advantage  is  to  be  derived  from  scraping 
and  cauterizing  the  surface  of  a  cauliflower-like  growth.  If  acute 
obstruction  occurs  (it  is  rare  except  in  carcinoma  of  the  sigmoid)  a 
false  anus  should  be  established  in  the  sigmoid,  or  if  the  obstruction 
has  existed  very  long,  in  the  cecum,  where  the  gut  is  healthier.  Unless 
obstruction  is  present  or  death  only  a  matter  of  a  few  months,  many 
patients  will  prefer  to  suffer  rather  than  be  relie^•ed  at  the  expense  of 
an  iliac  anus;  but  if  the  latter  is  properly  constructured  and  cared  for, 
it  produces  very  little  disability,  and  relieves  the  patient  of  untold 
discomfort  by  producing  latency  of  rectal  symptoms. 

Formation  of  a  False  Axus. — Through  a  left-sided  ]^IcBurney 
incision  a  loop  of  sigmoid  is  drawn  out,  and  its  afferent  limb  drawn 
taut.  If  this  precaution  is  neglected  prolapse  of  the  descending  colon 
may  occur  through  the  false  anus.     Then  the  afferent  and  efferent 


C.17i:C7A'O.U.l    OF   THE  RECTUM 


915 


loops  are  stitclu'd  totietluT  aloni;  tlu'ir  iiu'Sfiitfric  honlers,  for  a  dis- 
tance of  al)()Ut  six  inches,  so  as  to  form  an  efficient  spur.  The  loop  of 
bowel  is  then  replaced  and  sutured  in  the  abdominal  wound  at  the 
level  of  the  mesentery  (Fij;.  .S<S5).  If  the  operation  is  done  for  acute 
obstruction  a  Paul's  tube  should  be  fixed  in  the  proximal  loop  imme- 
diately. Otherwise  it  is  not  necessary  to  oj)en  the  gut  for  several  days; 
the  opening  is  then  accomplished  i)y  a  transverse  incision.  Subsequent 
treatment  involves  occasional  irrigation  of  the  rectal  loop  through 
the  false  anus,  to  clear  it  of  discharges  (which  are  much  diminished 
after  diversion  of  the  feces  from  the  ulcerating  area),  and  regular  daily 
irrigation  of  the  colon  through  the  upper  opening.  If  the  colon  is 
thoroughly  flushed  out  exevy  morning,  by  a  pint  or  more  of  warm 
w^ater,  and  if  this  injection  is  retained  for  about  twenty  minutes,  free 
evacuation  of  the  bowel  is  secured  by  turning  face  downward  and 
exerting  pressure  over  the  cecum.  "The  patient  is  then  quite  com- 
fortable and  clean  for  the  rest  of  the  dav"  (Wallis). 


Fig.  885. — Establishment  of  a  permanent  false  anus  by  suturing  the  afferent  and 
efferent  loops  together  "en   canon  de  fusil."    A  Paul's  tube  has  been  tied  in  each  end. 


Radical  Operation. — About  a  week  is  required  to  get  the  intestinal 
tract  in  proper  shape  for  operation,  and  commencing  the  night  before 
large  doses  of  deodorized  tincture  of  opium  should  be  given  (Tuttle). 
In  cases  of  acute  obstruction,  or  if  the  sphincters  will  have  to  be 
removed,  a  preliminary  colostomy  (as  above  described)  should  have 
been  done  about  two  weeks  before  radical  operation.  Opportunity 
should  also  be  taken,  when  the  abdomen  is  opened,  to  palpate  the 
liver  for  metastatic  growths. 

1.  Where  the  growth  i7n'odes  the  sphincters,  these  and  the  rectum  as 
high  as  the  sacral  promontory  are  removed;  and  the  pelvic  end  of  the 
rectum  is  closed  and  allowed  to  drain  through  the  p^e^■iously  estab- 
lished iliac  anus.  The  perineal  wound  is  completely  closed,  with 
drainage  to  the  hollow  of  the  sacrum.  The  inguinal  lymphatics  should 
be  extirpated  also. 


916  SURGERY  OF   THE  dASTRO-lNTESTINAL   TRACT 

2.  For  a  growth  just  above  the  anus,  in  which  the  sphincters  can  be 
preserved,  I  think  the  perineal  operation  as  modified  by  Peck  (1909) 
should  be  done:  The  anus  is  closed  by  a  purse-string  suture;  then  an 
incision  is  made  from  coccyx  to  rectum  and  is  carried  forward  on  each 
side  of  the  anus  in  Y-shape.  The  coccyx  may  be  excised,  but  further 
removal  of  bone  from  the  sacrum  (Kraske,  1885)  does  not  materially 
facilitate  the  operation.  Both  of  the  levator  ani  muscles  are  cut  just 
above  the  anus;  the  rectum  is  separated  all  around  its  ciroimiference 
and  is  doubly  ligated,  below  the  growth,  divided  between  the  (linen) 
ligatures  and  the  cut  surfaces  are  seared  with  the  actual  cautery. 
The  peritoneum  is  then  opened,  the  rectum  is  freed  anteriorly  from 
bladder  and  prostate,  as  well  as  laterally  and  posteriorly,  and  is  drawn 
down  until  an  area  well  above  the  growth  is  exposed.  It  is  here  again 
doubly  ligated,  divided  and  cauterized,  and  the  tumor  is  remo^Td. 
The  occluding  suture  is  then  removed  from  the  anus,  the  sphincter  is 
split  posteriorly,  and  the  anal  mucous  membrane  is  excised.  The 
proximal  segment  of  bowel,  still  closed  by  ligature,  is  then  drawn 
down  until  it  projects  well  beyond  the  sphincter,  which  is  sutured 
around  it.  The  peritoneum  and  levatores  ani  are  then  repaired,  the 
hollow  of  the  sacrum  is  drained,  and  the  unopened  bowel  is  left  pro- 
truding from  the  anus.  When  several  days  have  passed,  and  granula- 
tion has  begun,  so  that  little  fear  of  infection  remains,  the  redundant 
bowel  (perhaps  sloughing  in  parts)  is  cut  away,  and  fecal  discharge  is 
allowed.  Fair  sphincter  control  is  preserved;  the  immediate  mortality 
of  such  an  operation  is  from  10  to  20  per  cent.;  and  from  20  to  60  per 
cent,  of  patients  pass  the  three-year  interval  without  recurrence. 

3.  For  high  rectal  carcinoma  (all  tumors  above  easy  reach  of  the 
finger),  a  combined  abdominal  and  perineal  extirpation  is  the  accepted 
procedure,  though  the  primary  mortality  even  in  skilled  hands  is 
very  high  (25  to  50  per  cent.),  and  the  permanent  cures  average 
only  about  16  per  cent.  This  method  was  first  introduced  by  Maun- 
sell,  and  has  been  popularized  in  France  by  Quenu  and  Hartmann 
(1897),  and  in  this  country  by  Tuttle  and  the  jNIayos.  I  believe  ^yeir's 
modification  (1901)  of  the  method,  in  which  the  sphincter  is  preserved, 
is  better  than  the  plan  of  Quenu  in  which  the  entire  rectum  is  removed 
and  an  iliac  anus  established,  though  the  latter  is  the  method  preferred 
by  Tuttle  and  ]\Iayo.  The  surgeon  commences  by  opening  the  abdo- 
men in  the  mid-line  and  examining  the  parts.  If  the  tumor  is  high 
enough  in  the  sigmoid  an  ordinary  intestinal  resection  may  be  done, 
with  end-to-end  union,  or  where  possible  by  lateral  anastomosis,  which 
is  safer.  If  the  tumor  is  too  low  to  make  this  possible,  the  sigmoid 
is  divided  a  safe  distance  ((i  inches)  above  the  growth,  both  ends  being 
closed  at  once  by  suture.  The  meso-rectum  is  then  divided,  and,  after 
ligation  of  the  superior  hemorrhoidal  artery,  the  rectum  and  fatty 
and  lymphatic  tissue  behind  it  can  be  stripped  oft'  the  sacrum  quickly, 
and  with  very  little  hemorrhage  (Fig.  886).  The  rectum  is  then  doubly 
clamjjed  below  the  growth,  di\'ided,  cauterized,  and  the  diseased  bowel 
removed.     Next  the  sigmoid  and  perhaps  the  descending  colon  must 


CARCINOMA    Ol'   Till':   HECTUM 


or 


Fig.  8S6. — Abdomino-anal  operation  for  carcinoma  of  the  rectum:  the  sigmoid  has 
been  divided  and  both  ends  closed:  the  rectum  has  been  freed  from  the  hollow  of  the 
sacrum. 


Fig.  887. — -Blood-supply  of  the  pelvic  colon  and  rectum:  1,  ligature  on  the  superior 
hemorrhoidal  artery;  2,  ligature  on  the  inferior  mesenteric;  3,  ligature  on  a  descending 
branch  of  the  left  colic  artery. 


918  SURGERY  OF   THE  GASTRO-INTESTIXAL   TRACT 

be  freed  sufficiently  to  enable  the  reniaininj^  IxAvel  to  be  brought 
down  to  the  anus.  This  is  accomplished  l)y  inobUization  of  the  sigmoid 
(P.  Duval,  1902):  the  outer  leaf  of  the  meso-sigmoid  is  divided,  and 
the  bowel  is  turned  toward  the  median  line  by  gauze  dissection, 
restoring  it  to  the  condition  which  existed  in  intra-uterine  life.  By 
ligation  and  section  of  the  sigmoid  arteries,  and  if  necessary  of  the 
inferior  mesenteric  itself,  close  to  the  root  of  the  meso-sigmoid  (Fig. 
887)  sufficient  circulation  is  preserved  through  the  loops  of  communica- 
tion from  the  left  colic  or  e^•en  from  the  middle  colic  artery  (Archibald, 
1908).  Ample  slack  of  sigmoid  and  descending  colon  having  been 
secured  in  this  manner,  an  assistant  introduces  forceps  into  the  anus 
from  the  perineum,  and  evaginates  the  lower  segment  of  the  rectum; 
next  he  pulls  down  through  its  lumen  the  upper  segment  (sigmoid). 
The  abdominal  wound  is  then  closed,  after  repair  of  the  pelvic  peri- 
toneum. The  evaginated  rectum  and  sigmoid  are  then  securely  sutured 
together,  and  are  finally  replaced  in  the  pelvis  by  reducing  the  evagina- 
tion.  Drainage  of  the  pelvis  is  pro^•ided  by  an  incision  in  front  of 
the  coccyx. 

If  an  iliac  anus  has  been  made  previously,  for  obstruction  or  any 
other  reason,  it  is  better  to  excise  the  entire  rectum,  including  the 
sphincters,  and  to  close  the  perineum. 


(    IIAI'TKI{    XXIV. 

SURGERY  OF  THE  (JALL  BLADDER.  LIVER,  PAXCREAS, 

AND  SPLEEN. 

SURGERY    OF    THE    GALL  BLADDER    AND    BILE  DUCTS. 

Infections  of  the  Gall-bladder  and  Bile-ducts. — It  has  been  shown 
by  Adanii  and  others  that  bacteria  are  constantly  being  transmitted 
from  tlie  intestinal  tract  throuj^h  the  portal  cirrnlafiou  to  the  lixer. 
The  liver  is  endowed  with  antibacterial  and  antitoxic  properties, 
and  under  normal  conditions  the  bacteria  received  in  the  way  described 
are  destroyed  in  the  liver.  But  if  the  virulence  of  the  bacteria  is 
increased,  or  the  destructive  action  of  the  liver  lessened,  then  such 
bacteria  are  excreted  from  the  liver  with  the  bile.  The  gall-bladder  is 
a  suitable  place  for  bacteria  to  multiply,  both  from  its  anatomy,  and 
from  certain  characteristics  which  are  easily  acquired.  The  bile  tends 
to  stagnate  in  the  gall-bladder  because  of  the  tortuosity  of  the  cystic 
duct,  because  the  fundus  of  the  gall-bladder  is  lower  than  its  outlet, 
and  above  all  because  persons  of  sedentary  habits  and  those  who  wear 
tight  corsets  do  not  aid  the  expulsion  of  bile  from  the  gall-bladder 
by  active  exercise  of  the  diaphragm  and  abdominal  muscles.  It  is 
possible  also,  and  not  very  infrequent,  for  the  gall-bladder  to  be  infected 
by  way  of  the  systemic  circulation,  through  the  cystic  artery.  This  is 
probably  the  case  in  typhoid  fever,  in  which  disease  the  infecting 
bacillus  usually  can  be  obtained  in  pure  culture  from  the  gall-bladder. 
An  infection  by  way  of  the  common  hile-duct,  ascending  from  the 
duodenum  is  rare. 

If  the  infection  which  reaches  the  gall-bladder  either  through  its 
contained  bile,  or  through  the  blood-stream,  is  very  severe,  the  result- 
ing changes  in  the  gall-bladder  are  acute  in  type.  The  pathology  of 
acute  inflammation  of  the  gall-bladder  (cholecystitis)  corresponds  to 
that  already  discussed  in  connection  with  the  appendix.  The  walls 
of  the  gall-bladder  are  the  seat  of  round-celled  infiltration  {phleg- 
monous inflammation)  and  this  may  lead  to  gangrene  or  to  perforation 
of  the  organ.  If  the  infection  which  reaches  the  gall-bladder  is  very 
mild,  a  slight  catarrhal  inflammation  occurs,  and  the  interaction  of  the 
cholesterin  set  free  in  this  way  with  the  salts  contained  in  the  bile 
results  in  the  formation  of  concretions  known  as  gall-stones  or  biliary 
calculi. 

Cholecystitis. — The  pathogenesis  of  this  condition  has  been  described 
It  is  rare  except  as  a  complication  of  gall-stone  disease  (cholelithiasis, 
p.  922).    Swelling  of  the  spiral  folds  of  mucous  membrane  lining  the 


920     SURGERY  OF   rilE  GALL-BLADDER  AND  BILE-DUCTS 

cystic  duct  converts  the  gall-bladder  into  a  closed  cavity,  and  the 
virulence  of  the  infection  is  thus  increased.  If  suppuration  occurs 
within  the  gall-bladder  the  condition  is  described  as  empyema  of  the 
gall-bladder.  If  inflammation  spreads  to  the  surrounding  peritoneal 
structures,  pericholecystitis  is  said  to  exist.  Even  if  the  disease  is 
arrested  before  gangrene  or  perforation  occurs  a  return  to  normal 
does  not  ensue;  pericholecystitis  leaves  as  a  legacy  pericholecystic 
adhesions  which  bind  the  gall-bladder  to  the  duodenum,  pylorus,  or 
omentum,  and  which  may  cause  kinking  of  the  bile-ducts;  while 
changes  in  the  wall  of  the  gall-bladder  and  in  the  cystic  duct  impair 
still  more  its  drainage  facilities,  and  stricture  or  occlusion  of  the  cystic 
duct  may  convert  the  gall-bladder  into  a  permanently  closed  cavity 
with  contents  of  very  low  infectious  power,  a  condition  described  as 
hydrops  of  the  gall-bladder.  Chronic  cholecystitis  may  occur  as  a  sequel 
of  an  acute  attack,  or  if  the  infection  is  mild  the  cholecystitis  may  be 
chronic  from  the  beginnins'.  It  is  very  rare  except  in  cases  of 
cholelithiasis. 

Symptoms  of  Acute  Cholecystitis. — The  patient  usually  is  an  adult 
in  early  middle  life.  The  affection  is  rare  before  thirty  years  of  age, 
and  not  very  frequent  in  those  over  forty  years,  unless  previous  attacks 
have  occurred.  The  attack  usually'  begins  with  biliary  colic  (p,  924) 
which  may  be  mild  or  severe.  It  is  a  mistake  to  suppose  that  biliary 
colic  occurs  only  when  gall-stones  are  present;  as  in  the  case  of  the 
appendix,  the  intestine,  and  the  kidney,  the  colic  is  a  sign  of  disordered 
and  violent  peristalsis  in  an  effort  of  the  organ  to  empty  itself  against 
resistance.  The  resistance  may  be  formed  by  a  gall-stone  impacted 
in  the  neck  of  the  gall-bladder  or  in  one  of  the  ducts,  but  it  often 
is  formed  by  inflammatory  occlusion  of  the  cystic  duct,  or  by  an 
exceedingly  viscid  and  tarry  state  of  the  bile  which  is  a  frequent 
condition  in  the  stagnant  gall-bladder.  In  many  cases  of  cholecystitis 
the  pain  is  not  very  severe  at  first,  and  is  felt  in  the  epigastrium,  or 
is  diffused  through  the  abdomen;  soon,  howe^'er,  it  settles  to  the  gall- 
bladder region,  to  the  right  of  the  epigastrium  or  in  the  right  In'po- 
chondrium.  Sometimes  referred  pain  is  felt  in  the  right  shoulder, 
under  the  scapula,  or  in  the  right  iliac  fossa.  If  the  gall-bladder  lies 
low  in  the  abdomen  the  attack  may  be  confused  with  appendicitis. 
Nausea  and  romititig  usually  occur,  but  may  be  entirely  absent. 
Muscular  rigidity  and  tenderness  over  the  site  of  the  gall-bladder  are 
constant  and  very  valuable  signs.  The  gall-bladder  becomes  enlarged 
and  usually  can  be  outlined  by  percussion,  and  if  rigidity  and  tender- 
ness are  not  very  great,  it  may  be  palpable  as  a  smooth  rounded  tumor 
beneath  the  costal  margin  continuous  with  the  liver  dulness  and  moving 
in  respiration  unless  fixed  by  adhesions  from  previous  disease.  Jaundice 
does  not  occur  in  uncomplicated  cases  of  cholecystitis;  it  implies 
involvement  of  the  common  or  hepatic  ducts.  There  usually  is  fever, 
but  the  temperature  seldom  is  very  high;  there  is  polynuclear  leuko- 
cytosis. If  there  is  much  constitutional  reaction,  and  if  the  elevation 
of  temperature  continues  for  several  days  and  is  high,  empyema  or 


CfWLANGEITIS  921 

threatening  gangrene  shoultl  he  suspected.  Perforation  into  the  free 
peritoneal  cavity  is  very  rare  (Fi^.  S()7),  and  is  unusual  even  into 
preformed  pericliolecystic  adhesions.  It  may  he  recognized  in  some 
ca.ses  hy  sudden  sexere  })ain,  jxTliaps  with  symptoms  of  shock,  fall  of 
temperature,  rise  of  jnilse  rate,  and  occasionally  hy  the  sudden  dis- 
appearance of  a  gall-hhidder  tumor  previously  palpahle.  Unless  the 
upper  alxlomen  is  well  protected  hy  adhesions,  spreading  peritonitis 
ensues.  In  the  former  case  a  jK'richolecystic,  sul)i)hrcnic  or,  rarely, 
a  perinephric  ahscess  results.  Spontaneous  perforation  through  the 
ahdominal  wall  {external  biliary  fistula),  or  into  the  gastro-intestinal 
tract  {infernal  biliary  fistula)  is  very  rare. 

Diagnosis. — Acute  cholecystitis  must  be  distinguished  from  appen- 
dicitis (p.  S52),  gastric  or  duodenal  perforation  (p.  807),  intestinal 
obstruction  (p.  886),  and  acute  pancreatitis  (p.  945).  In  most  cases 
the  correct  diagnosis  is  easy,  owing  to  localization  of  the  signs  and 
symptoms  to  the  gall-bladder  region,  and  the  recognition  of  the 
enlarged  gall-bladder. 

Treatment. — The  patient  should  be  treated  by  rest  in  bed,  in  the 
semi-rccumbent  position ;  absolute  prohibition  of  food  or  liquid  by  the 
mouth;  hot  or  cold  applications  to  the  upper  right  quadrant  of  the 
abdomen;  and  proctoclysis  of  saline  fluid  or  tap  water.  Most  mild 
cases  of  cholecystitis  will  subside  within  a  day  or  two  under  this 
treatment.  If  anything  is  taken  into  the  stomach  peristalsis  is 
aroused,  and  there  is  danger  of  spreading  the  infection  from  the  gall- 
bladder to  the  bile  ducts  or  to  the  surrounding  peritoneal  structures. 
When  all  acute  symptoms  have  been  absent  for  a  day  or  so,  sodium 
phosphate  in  hot  water  may  be  given  by  mouth,  and  then  feeding 
may  be  cautiously  resumed.  If  the  attack  does  not  subside  promptly, 
suggesting  the  probable  occurrence  of  suppuration  within  the  gall- 
bladder, the  organ  should  be  drained  {cholecystostomy,  p.  930). 

Cholangeitis. — Cholangeitis,  or  inflammation  of  the  bile-ducts,  is 
rare  except  as  a  complication  of  gall-stone  disease,  or  as  a  sequel  of 
catarrhal  gastro-duodenitis  ("catarrhal  jaundice").  In  this  condition 
the  duodenal  mucous  membrane  around  the  bile-papilla,  and  that 
in  the  lower  end  of  the  common  duct,  swell  up  and  cause  obstruc- 
tion of  the  biliary  outlet,  resulting  in  the  development  of  jaundice. 
In  many  of  these  cases  it  is  probable  that  swelling  of  the  head  of  the 
pancreas  also  occurs  and  compresses  the  common  bile  duct,  which 
is  known  to  transverse  its  substance  in  two  out  of  three  cases.  If 
the  attack  of  jaundice  occurs  in  the  young,  it  usually  is  due  to  gastro- 
duodenal  catarrh;  jaundice  in  middle  aged  or  old  patients  usually 
is  due  to  gall-stone  disease,  pancreatitis,  or  malignancy.  In  the  latter 
conditions  pain  is  more  marked  (usually  it  is  entirely  absent  in  catarrhal 
jaundice);  the  jaundice  is  of  longer  duration  (usually  it  subsides  in 
a  week  or  ten  days  in  cases  of  gastro-duodenal  catarrh);  it  varies  in 
intensity  unless  there  is  obstruction  by  a  malignant  growth  or  pancre- 
atitis; and  attacks  of  chills  and  fever  are  much  more  common  than 
in  attacks  of  catarrhal  jaundice.     Chronic  catarrhal  cholangeitis  and 


022      SURGERY  OF   THE  GALL-BLADDER  AND  BILE-DUCTS 

suppurative  cholangeitis  are  very  rare  except  in  connection  with  ,i,^all- 
btonc  disease. 

Treatment. — Cholangeitis  due  to  gastro-duodenal  catarrh  subsides 
I)r()ni]>tl}'  under  ai)propriate  medical  treatment.  Tn  other  cases  the 
treatment  is  that  of  the  causati\'e  condition. 

Cholelithiasis. — The  formation  of  gall-stones  has  already  been 
alluded  to.  TJie  chief  predisposing  condition  is  stagnation  of  bile 
in  the  gall-bladder.  x\s  the  stagnant  gall-bladder  is  more  frequent  in 
women  than  in  men,  so  is  the  occurrence  of  gall-stone  disease.  The 
stagnated  bile  becomes  viscid,  ropy,  and  very  dark  in  color.  It  invites 
infection,  and  when  such  infection  occurs,  in  attenuated  form,  the 
union  of  cholesterin  derived  from  the  mucous  membrane,  with  bile 
salts,  results  in  the  formation  of  concretions  (gall-stones).  Biliary 
sand,  composed  of  minute  cholesterin  crystals,  is  found  not  very 
infrequently  in  such  a  gall-bladder,  which  is  otherwise  apparently 
normal.  This  sand  clings  to  the  mucosa  of  the  gall-bladder  and  can- 
not be  detected  with  the  finger  because  so  fine  and  so  well  covered 
by  mucus;  it  can  be  seen  glistening  on  the  gauze  which  has  wiped  the 
gall-bladder  cavity.  Such  a  gall-bladder  has  been  described  by  Moy- 
nihan  as  the  ''Cholesterin  Gall-bladder,"  and  by  Wilson,  of  the  Mayo's 
clinique,  as  the  "Strawberry  Gall-bladder,"  from  the  appearance  of 
the  minute  yellow  specks  on  the  inflamed  mucous  membrane.  It  is 
held  by  Aschoff  and  Bacmeister  (1909)  that  a  concretion  composed 
of  pure  cholesterin  may  be  formed  in  the  gall-bladder  without  the 
presence  of  bacterial  infection;  they  teach  that  this  stone  precedes 
the  formation  of  all  other  varieties,  which  mav  be  ninnerous. 


Fig.  888. — Radial  chijlostorin  stcjiic;  spontaneous  fracture  in  gall-bladder.  Female, 
aged  fifty  years,  with  empyema  of  gall-bladder.  Recovery.  (See  Fig.  889.)  Episcopal 
Hospital. 


The  following  varieties  of  gall-stones  may  be  recognized:  (1)  The 
pure  cholesterin  stone  (Figs.  888  and  889)  usually  is  of  fairly  large 
size  and  oval  in  shape;  it  is  soft  when  first  formed  but  becomes  hard 
and  brittle  on  drying;  is  white,  yellowish,  or  brownish  black  on  the 
surface,  but  white  and  crystalline  on  section.  It  is  not  stratified,  but 
is  composed  of  radiating  crystals  around  a  comparatively  soft  centre, 
which  in  the  dried  specimen  may  be  hollow.  (2)  Laminated  cholesterin 
stone.  Laminations  indicate  that  secondary  deposits  of  bile  salts  have 
occurred  around  the  primary  radial  cholesterin  stone,  (o)  The  common 
gall-stones,  or  mixed  cholesterin  calculi,  vary  greatly  in  number  and  size 


CIIOLELITIIIASIS 


923 


iiiui  usiuillv  arc  fiu-eted;  the  surfacr  color  usually  is  ycllowisli.  They 
arc  all  formed  at  or  about  the  same  time,  aud  arc  pressed  nito  their 
faceted  siiape  while  still  soft  (FiK^  Nf><>).  (^  Mixed  bilirubin-calcium 
stones  are  less  usual,  generally  occur  siugly,  or  in  groups  of  three  (.r 
four,  ou  sectiou  show  conccutric  layers  of  dark  reddish-hnnvu  materiaj; 
and'ou  drviim-  usually  coutract  witli  the  formation  of  fissures.  (5) 
Pure  bilirubin-calcium  stones  also  occur,  as  do  certain  still  rarer  forms. 


S.imc  stone  as 
tal. 


Yu:    .SS9.— Cholest.'i-in  fiall-stone,  with  polishofl  facot  at  eac-li  end.      ^amo  s 
Fig.  88S,  aftor  fraKmcnts  liad  Ix-cn  sluod  toKothcr.      iMMscopal  Ho.spit 

Gall-stones  are  the  result  of  previous  disease  in  the  gall-bladder,  and 
may  form  so  silently-  that  little  indication  of  their  presence  is  given 
until  some  acute  infection  arises,  causing  acute  calculous  cholecystitis, 
or  cholangeitis.  Thev  are  formed  in  the  gall-bladder,  not  in  the  liver 
or  bile  ducts,  and  so  long  as  they  remain  in  a  gall-bladder  free  from 
infection  mav  produce  no  noteworthy  symptoms.  This  state  is 
described  as  "simple  Cholelithiasis.     But  the  presence  of  the  concre- 


FiG  890.— Common  gall-stones,  from  a  gall-bladder  removed  for  acute  calculous 
cholecystitis,  in  a  woman,  aged  thirty-seven  years.  Dyspepsia  for  years  and  much 
bek'hiiig  aft  Jr  meals.  Wakened  one  midnight  by  epigastric  pain ;  two  days  later  enlarged 
gall-bladder  palpated;  admitted  for  operation  on  third  day;  cholecystectomy;  recovery. 
Episcopal  Hospital. 

tions  predisposes  the  gall-bladder  to  infection,  and  if  one  or  more  of 
the  calculi  wander  from  the  gall-bladder  and  enter  the  cystic  or  the 
common  duct,  very  serious  symptoms  may  arise.  At  operation  these 
ducts  are  found  to'  have  been  invaded  by  one  or  more  calculi  in  nearly 
40  per  cent,  of  cases  (Deaver  and  iVshhurst). 

Simple  CholeUthiasis.— This  has  been  defined  above.  The  gall- 
stones ha^•e  remained  quiescent  in  the  gall-bladder  since  the  time  of 
their  first  formation,  perhaps  many  years  previously.     The  symp- 


924     SURGERY  OF   THE  GALL-BLADDER  AND  BILE-DUCTS 

toms  are  due  to  a  chronic  catarrhal  cholecysiitls,  and  the  pathological 
changes  in  the  gall-bladder  are  not  very  marked.  The  bile  is  thick 
and  tarry,  but  so  long  as  no  acute  infection  occurs  the  patients  are 
not  much  troubled.  But  certain  ssonptoms  are  present  by  which  the 
disease  may  be  recognized,  and  they  can  be  discovered  by  studying 
carefully  the  history  of  the  case.  These  symptoms  usually  are  con- 
sidered gastric  in  origin,  and  the  patient  attributes  to  "indigestion" 
fleeting  attacks  of  pain,  dull,  boring,  or  grasping  in  character,  which 
occur  in  the  epigastrium,  but  which  are  irregular  in  their  occurrence 
and  are  dependent  on  no  recognized  factor.  Pylorospasm  may  occur, 
but  vomiting  is  rare,  as  is  acute  pain.  If  slight  pressure  over  the  gall- 
bladder region  relieves  the  discomfort  it  is  probable  that  perichole- 
cystic  adhesions  are  present.  In  cases  of  simple  cholelithiasis  there 
may  be  tenderness  over  the  gall-bladder,  and  various  special  points 
of  tenderness  (corresponding  to  McBurney's  point  in  appendicitisj 
ha\'e  been  described,  but  I  have  not  found  them  of  practical  signifi- 
cance. With  the  patient  sitting  and  leaning  forward,  the  surgeon 
may  stand  behind  him,  with  one  hand  hooked  under  each  costal  margin 
at  the  ninth  costal  cartilage.  If  at  the  end  of  deep  inspiration,  which 
forces  the  gall-bladder  against  the  finger  tips,  the  patient  experiences 
a  sudden  severe  pain,  it  is  the  opinion  of  some  that  gall-stones  are 
present.  This  is  known  as  ^Murphy's  test  for  cholelithiasis;  I  have 
repeatedly  found  it  unreliable.  With  the  patient  recumbent,  the  right 
loin  may  be  supported  with  tlie  left  hand,  while  with  the  finger  tips 
of  the  right  the  gall-bladder  is  palpated  beneath  the  costal  margin. 
Sometimes  at  the  end  of  deep  inspiration  it  can  be  felt  and  if  diseased 
usually  is  tender  and  painful.  There  is  also  very  commonly  a  tender 
spot  to  the  right  of  the  twelfth  dorsal  vertebra  (Boas's  area). 

Biliary  Colic. — Biliary  colic  usually  has  occurred  once  or  oftener 
before  patients  come  to  the  surgeon  for  operation.  As  stated  already, 
it  may  occur  where  no  calculi  are  present.  In  the  mildest  cases  the 
pain  may  be  fleeting,  and  the  patient  may  forget  its  occurrence  unless 
closely  questioned,  especially  as  the  earlier  attacks  of  colic  usually 
cause  pain  in  the  mid-epigastrium  and  not  over  the  gall-bladder.  In 
other  cases,  however,  the  initial  attack  is  severe.  A  man,  believing 
himself  to  be  in  the  enjoyment  of  excellent  health,  except  for  slight 
gastric  symptoms  which  have  never  incommoded  him,  may  suddenly 
have  a  dreadful  cramp  in  his  upper  abdomen;  he  bends  forward  press- 
ing his  hands  or  the  back  of  a  chair  into  his  belh';  breaks  out  in  a 
cold  sweat;  becomes  deathly  pale  and  feels  faint;  is  nauseated;  and 
sometimes  his  distress  is  relieved  by  vomiting.  Or  he  may  writhe 
around  his  bed,  or  even  on  the  floor  in  utmost  agony.  When  the 
obstruction  is  relieved  by  the  calculus  falling  back  into  the  gall-bladder 
or  by  the  cystic  duct  becoming  patulous,  pain  ceases  instantly.  If 
obstruction  continues  pain  does  not  vanish,  but  continues  for  hours 
or  days,  but  not  so  intense  as  at  first.  The  pain  now  shifts  to  the 
gall-bladder  region,  and  may  be  referred  to  the  back  or  shoulder 
through  filaments  of  the  fourth  cervical  nerve,  from  wliich  the  phrenic 


MICUA  I'h'l)   <;.\LL-ST()NES 


wi:) 


is  ck'rhod.  W  lien  tliore  is  fomplete  obstruction  of  the  cystic  duct, 
colicky  pain  quickly  disappears. 

Acute  Calculous  Cholecystitis  is  a  fn^qnent  occurrence  in  cases  of 
sinii)lc  cliolelitliiasis.  The  symptoms  do  not  dili'er  from  those  of  non- 
calculous  cholecystitis  (p.  920),  and  it  is  largely  on  the  recurrence  of 
synij)tonis  that  the  diagnosis  of  gall-stones  is  based. 

Migrated  Gall-stones.  -In  many  cases  of  cholelithiasis  it  is  possible 
to  determine  whether  the  calculi  remain  in  the  gall-bladder  or  have 
escaped  into  tlie  bile  ducts,  and  especially  whether  or  not  the  common 
duct  is  involved.  As  only  a  few  of  the  calculi  usually  leave  the  gall- 
bladder the  clinical  picture  maj'  be  somewhat  confusing. 

Stone  in  the  Cystic  Duct. — As  soon  as  a  stone  enters  the  duct,  typical 
gall-stone  colic  results  and  paroxysms  of  pain  recur  until  the  stone 
either  pusses  through  the  duct, 
returns  to  the  gall-bladder,  or  is 
arrested  permanently  in  the  duct. 
If  in  the  latter  case  obstruction 
is  complete,  colic  gradually  ceases, 
and  usually  the  gall-bladder  be- 
comes distended  and  enlarged, 
causing  at  first  empyema,  and  later, 
if  the  infection  becomes  attenuated, 
hydrops.  In  many  cases,  however, 
when  a  stone  is  lodged  in  the  cystic 
duct,  it  forms  a  diverticulum  for 
itself  and  bile  can  still  enter  and 
leave  the  gall-bladder.  Perforation 
incases  of  cholelithias  is  occurs  usu- 
alh'  at  or  near  the  origin  of  the 
cystic  duct;  while  in  non-calculous 
cholecystitis  it  occurs  oftenest  at 
the  fundus  of  the  gall-bladder. 

Stone  in  the  Common  Duct. — It  is 
rare  for  a  stone  to  pass  completely 
through  the  choledochus.  The  larger 
stones  are  arrested  in  its  supra- 
duodenal portion,  and  the  smaller 
in  its  retroduodenal  or  in  the 
ampulla  of  Vater.  Complete  ob- 
struction, when  it  occurs,  seldom 
lasts  more  than  a  week  or  ten  days, 
the    acute    attack    then    subsiding 

and  perhaps  not  recurring  again  for  weeks  or  months.  Each  attack 
of  colic  is  characterized  by  jaundice,  fever,  and  marked  constitutional 
disturbance.  These  are  absent  in  simple  biliary  colic.  They  are  due 
to  recurrent  attacks  of  cholangeitis,  causing  temporary  complete 
occlusion  of  the  choledochus  with  damming  up  of  bile  and  pus,  xery 
seriously  threatening  the  integrity  of  the  liver,  and  frequently  bringing 


Fig.  891. — Sites  6!  lodgement  of  nii- 
firated  biliary  calculi:  in  the  neck  of 
the  gall-bladder;  in  the  cystic  duct;  in 
the  hepatic  duct;  in  the  common  duct 
(supra-duodenal,  retro-duodenal,  or  pan- 
creatic portion),  or  at  the  papilla  of 
Vater. 


92G     SURGERY  OF   THE  GALL-BLADDER  AND  BILE-DUCTS 

the  patient  to  death's  door.  The  calculus  does  not  float  around  free 
in  the  bile-duct,  acting  as  a  ball-valve,  as  described  by  Fenger  (1696): 
at  operation  it  usually  is  found  firmly  fixed,  sometimes  in  a  divertic- 
ulum. The  fever  rises  abruptly  to  104°  F.  or  higher,  and  falls  again 
as  ra])idly  to  normal  or  subnormal.  It  is  known  as  "Charcot's  inter- 
mittent fever,"  ailtl  Moynihan  describes  the  temperature  record  as 
a  "steeple"  chart,  from  its  sudden  variations.  The  jaundice  also 
is  intermittent,  or  at  least  lessens  from  time  to  time,  and  stercobilin 
is  never  very  long  absent  from  the  feces.  Persistence  of  jaundice, 
with  its  accompanying  constitutional  condition,  known  as  cholemia, 
is  a  verj'  dangerous  feature,  and  the  tendency  to  hemorrhage  becomes 
very  marked,  owing  to  the  prolongation  in  the  clotting  time  o^'  the 
blood. 

When  there  is  calculous  obstruction  of  the  common  duct,  the  gall- 
bladder is  found  to  be  contracted  in  80  per  cent,  of  cases;  and  in  90 
per  cent,  of  cases  where  the  gall-bladder  is  enlarged,  the  obstruction 
is  due  to  causes  other  than  stone,  usually  malignant  disease.  This 
is  known  as  Courvoisier's  Law  (1890).  The  explanation  is  that  the 
gall-bladder  has  been  diseased  so  long  before  the  stones  migrate  into 
the  common  duct,  and  has  become  so  contracted  and  thickened  as  a 
result  of  disease,  that  it  can  no  longer  dilate  under  the  influence  of 
back  pressure. 

Stone  in  the  Hepatic  Duct. — Calculi  are  found  in  the  hepatic  duct 
only  when  they  have  floated  upward  from  the  common  duct,  or  when, 
the  common  duct  being  already  full  of  stones,  others  descending  from 
the  gall-bladder  have  to  pass  into  the  hepaticus.  Gall-stones  (except 
biliary  sand)  are  not  formed  in  the  liver  except  when  the  choledochus 
and  common  hepatic  duct  are  already  filled.  The  symptoms  of  stone 
in  the  hepatic  duct  cannot  be  distinguished  from  those  due  to  common 
duct  calculus. 

Treatment  of  Cholelithiasis. — In  cases  of  simple  choleUthiasis  operati\'e 
treatment  should  be  urged,  unless  any  operation  is  contraindicated 
by  extreme  age,  or  by  visceral  disease.  There  is  no  medicine  which 
will  cause  the  solution  of  the  stones,  though  charlatans  often  deceive 
patients  by  administering  olive  oil  in  large  quantities  and  telling  them 
that  the  fecal  concretions  so  produced  are  the  biliary  calculi.  But  it 
is  possible  by  strict  medical  treatment,  such  as  diet,  hygiene,  etc.,  to 
keep  the  disease  latent  for  many  years  in  some  cases;  and  most  patients 
who  can  afford  such  a  life  will  be  satisfied  to  adopt  this  procedure 
rather  than  operation.  But  they  should  be  informed  that,  as  Mayo 
writes,  the  danger  of  the  de\elopment  of  carcinoma  in  such  a  gall- 
bladder (see  p.  942)  is  five  times  as  great  as  is  the  mortality  following 
operation  for  the  relief  of  simple  gall-stone  disease,  when  performed 
by  a  competent  surgeon.  And  Kehr  says  "the  slight  dangers  of  early 
operation  stand  in  no  sort  of  a  relation  with  the  great  dangers  of  the 
disease  itself;  even  the  latent  cholelithiasis  we  should  always  regard 
with  suspicious  eyes,  for  the  quiet  work  of  gall-stones  is  often  the  most 
destructive.     In  jnalignancy  and  insidiousness,"  concludes  Kehr,  "??o 


T  UK  ATM  EST   OF   CHOLELITHIASIS  927 

(li,sr(tsc  of  iinin  com/xin's  irllli  cholcliihldsi.s."  It',  alter  their  attendant 
has  stated  the  tacts  ot"  the  case,  the  patients  still  will  not  he  operated 
on,  that  is  their  own  look-ont.  The  mortality  followinfi;  oj)eration  in 
these  simple  cases,  in  competent  hands,  is  less  than  5  per  cent. 

The  proper  operation  in  the  ^"ast  majority  of  cases  of  sinij)Ie  chole- 
lithiasis is  removal  of  tlie  calculi  and  drainaf^e  of  the  pill-bladder 
{cholecysiostomy,  p.  930) ;  only  if  the  gall-hladder  is  so  altered  by  dis- 
ease as  to  be  functionally  useless,  is  it  desirable  to  remove  it  {chole- 
cy.stiriomii,  ]).  \Y.\\).  ]iecurrence  of  gall-stones  after  cholecystostomy 
is  very  unusual,  and  generally  the  stones  that  are  found  subsequently 
are  not  newly  formed,  but  were  overlooked  at  the  first  operation. 
The  mortality  of  cholecystectomy  is  slightly  higher  than  that  of  simple 
drainage,  but  in  cases  of  acute  calculous  cholecystitis  it  is  to  be  j)referred, 
as  also  in  every  case  where  the  gdll-hhiddcr  is-  >nurh  cotitracied  or  thickened. 
and  in  cases  of  the  '' cholesterin  (jaU-hladder."  Cholecystectomy  is 
also  to  1)6  done  in  cases  of  obstruction  of  the  cystic  duct  by  a  calculus, 
since  stricture,  with  resulting  hydrops,  is  the  almost  inevitable  result 
of  removal  of  such  a  stone.  In  cases  of  hydrops  and  gangrene  always, 
and  in  most  cases  of  empyema  or  perforation  remo\al  of  the  gall-bladder 
is  indicated.' 

In  cases  of  stone  in  the  common  duct  the  patients  may  come  under 
observation  either  during  an  attack  of  obstruction  with  cholangeitis, 
or  during  a  free  interval.  In  the  latter  contingency  there  is  no  need 
to  ])ostpone  operation,  and  removal  of  the  stone  or  stones  should  be 
undertaken.  In  the  presence  of  acute  complete  obstruction  of  the 
common  duct,  however,  it  is  the  teaching  of  nearly  all  surgeons  that 
operation  should  be  dela^'ed  until  under  medical  treatment  (as  for 
acute  cholecystitis,  p.  921)  complete  obstruction  has  subsided.  Deaver 
and  Ashhurst  contend,  on  the  other  hand,  that  by  waiting  the  patient 
runs  the  risk  of  cholangeitis,  cholemia,  with  the  gravest  form  of  sepsis; 
not  to  mention  perforation  of  the  common  duct  or  the  formation  of 
almost  inoperable  adhesions,  or  the  indefinite  persistence  of  chronic 
jaundice  with  its  dangerous  hemorrhagic  tendencies.  The  fact  that 
the  mortality  of  operations  during  persistence  of  complete  obstruction 
is  \ery  much  higher  than  that  of  inter\-al  operations  is  not  a  valid 
argument  against  immediate  operation,  since  the  c(uestion  is  not 
the  death  rate  from  operation,  but  the  death  rate  from  the  disease. 
Dea^■er  says  "while  many  times  there  has  been  cause  to  regret  not 
operating  during  the  stage  of  acute  obstruction,  never  yet  has  there 
been  cause  to  regret  prompt  relief  of  the  obstruction  by  operation." 

The  operation  consists  in  removal  of  the  stones  in  the  common  duct 
(by  choledochotomy,  p.  932),  thorough  exploration  of  the  common 
and  hepatic  as  well  as  the  cystic  duct,  and  drainage  of  the  common 

'  Individuals!  known  as  "typhoid  carriers,"  in  whom  the  gall-bladder  acts  as  a 
store-house  for  typhoid  bacilli  which  are  discharged  with  the  feces,  and  who  often 
cause  epidemics  of  typhoid  fever,  may  be  surely  relieved  of  their  infecting  quali- 
ties by  removal  of  the  gall-bladder.  No  medicines  are  of  any  value,  and  anti- 
typhoid vaccination  has  been  tried  without  success. 


92S     OPERATIONS  ON   THE  GALL-BLADDER  AND  BILE-DUCTS 

duct  and  the  gall-bladder  by  separate  tubes.  Occasionally  the  gall- 
bladder has  to  be  removed. 

Obstruction  of  the  Common  Duct  may  result  from  stricture,  the 
result  of  previous  operative  interference,  or  from  tumor  formation, 
as  well  as  from  lodgement  of  calculi.  If  the  stricture  is  benign  in  nature, 
the  bile  should  be  short-circuited  into  the  intestinal  tract  by  an  anas- 
tomosis between  the  gall-bladder  and  duodenum  or  stomach.  If  the 
gall-bladder  has  been  removed,  and  cholecystenterostomy  is  therefore 
impossible,  an  anastomosis  will  have  to  be  made  between  the  dilated 
duct  above  the  obstruction  and  the  intestine  {choledocho-enterostomy , 
hepatico-enierostomy) .  If  the  obstruction  is  due  to  malignant  disease, 
no  operation  beyond  exploration  should  be  done,  unless  the  disease 
can  be  completely  removed.  Carcinoma  of  the  gall-bladder  and  bile- 
ducts  is  considered  at  p.  942. 

In  cases  of  postoperative  external  biliary  fistula  the  gall-bladder 
should  be  removed,  if  the  common  duct  is  patent;  if  the  gall-bladder 
has  already  been  removed  there  is  almost  certainly  obstruction  of  the 
common  duct.  In  either  case  obstruction  of  the  common  duct  is  to 
be  treated  as  above  indicated. 

OPERATIONS  ON  THE  GALL  BLADDER  AND  BILE  DUCTS. 

The  deeper  structures  may  be  made  much  more  accessible  by 
placing  a  sand-pillow  (about  four  to  six  inches  in  thickness)  beneath 
the  patient's  spine,  at  the  level  of  the  liver,  thus  throwing  the  upper 
abdomen  forward,  and  allowing  the  intestines  to  fall  toward  the 
pelvis.  The  head  and  shoulders  should  be  suitably  supported  so  as  to 
facilitate  administration  of  the  anesthetic.  In  very  difficult  cases  the 
foot  of  the  table  may  be  lov,ered  (reversed  Trendelenburg  posture) 
as  originally  advised  by  Elliot,  of  Boston,  who  introduced  in  1895  the 
position  above  described. 

The  incision  in  common  use  for  biliary  operations  is  that  known  as 
Mayo  Robsons  (Fig.  (S93) ;  in  simple  cases  only  the  longitudinal  incision 
through  the  rectus  muscle  is  necessary.  In  cases  which  promise  to  be 
very  difficult  Czerny's  W inkeJschnitt  (1S92)  is  to  be  preferred:  this 
runs  from  5  to  7  cm.  in  the  mid-line,  above  the  umbilicus,  and  bends 
to  the  right  just  below  the  umbilicus,  cutting  the  rectus  transversely. 
Kehr  has  abandoned  (1912)  his  original  bayonet  incision  (Welleti- 
schnitt)  and  now  employs  an  angular  incision  somewhat  like  Czerny's. 
Sprengel's  transverse  incision  which  divides  the  right  rectus  muscle 
directly  across  at  whatever  level  seems  desirable,  and  which  may  be 
extended  in  the  same  direction  if  necessary,  is  gaining  favor  in  Europe; 
Gosset  in  France  and  Korte  in  Germany  have  adopted  it.  Before 
suturing  any  of  these  incisions,  the  support  should  be  removed  from 
beneath  the  patient's  spine. 

After  the  abdomen  has  been  opened  the  parts  concerned  in  the  opera- 
tion must  be  well  protected  by  gauze  pads.  One  is  placed  in  the  sub- 
hepatic space  or  right  kidney  pouch,  a  second  presses  the  stomach 


AliDOMlSM.    ISCISIOSS 


929 


out  of  the  way  toward  the  left,  a  third  is  placed  oxer  the  ^astro- 
Iu'i)atic  omentum  just  below  the  liver,  and  a  fourth  is  packed  down 
toward  tlie  eeeum.  Sometimes  another  pad  is  placed  between  the 
rijjht  lobe  of  tlie  liver  and  the 
dia])hrajj;ni.  Tn  many  o|)crations 
it  is  possible  to  draw  the  lixcr, 
and  with  it  the  gall-bhulder, 
partly  out  of  the  wound.  If  the 
h)wer  border  of  the  liver  is  drawn 
slightly  downward  and  then 
lifted  upward  into  the  abdomi- 
nal incision,  sliji^htl}'  rotating 
the  organ  so  as  to  turn  its  in- 
ferior surface  toward  the  ])a- 
tient's  left,  it  fully  exposes  the 
gall-bladder  and  brings  the  cystic 
and  common  ducts  very  near  the 
surface.  In  this  way  the  cystic 
duct  forms  almost  a  straight  line 
with  the  common  duct,  which 
is  therefore  more  easily  found. 
An  assistant  should  hold  the  liver 
in  this  position  with  the  aid  of 
gauze  sponges.  Too  much  force 
must  not  be  used.  I  have  torn 
the  liver  in  trying  to  deliver  it. 


'^ 


\ 


Fig.  892. — Mayo  Robson's  and  Czerny's 
incisions  for  operations  on  the  biliary  tract. 
(See  text.) 


o 


Fig.  N'J.3. — Majo  Robsou  incision  for  cliolocystostomy.     Eijiseupal  Hospital. 
59 


930     OPERATIONS  ON   THE  GALL-BLADDER  AND  BILE-DUCTS 


Cholecystendysis  is  the  name  given  to  the  operation  in  which  after 
ojxMilng  the  gall-hhidrler  for  removal  of  calcnli,  it  is  at  once  sutured 
and  the  abdominal  wound  closed  without  drainage.  The  operation  is 
scarcely  e\er  done  at  present,  and  is  not  to  be  commended.  A  gall- 
bladder which  needs  to  be  opened  needs  also  to  be  drained. 

Cholecystotomy  and  Cholecystostomy. — The  former  term  implies 
merely  oi)eniiig  the  gall-bladder,  while  the  latter  indicates  that  it  is 
left  open  for  the  purpose  of  drainage.  The  terms  often  are  used 
synonomously.  The  gall-bladder  is  exposed  and  isolated  by  gauze 
packs.  If  distended  the  contained  fluid  is  remo\'ed  by  trocar  and 
cannula,  taking  care  to  prevent  contamination  of  surrounding  struc- 
tures or  the  abdominal  wound.  The  gall-bladder  is  then  pulled  into 
the  wound  and  opened  at  .the  fundus  with  scissors,  and  the  finger  is 
introduced  for  exploration. 

Gall-stones  are  removed  with  scoop,  forceps,  or  spoon.  Thick  and 
tarry  bile  is  wiped  out,  and  the  surgeon  makes  sure  that  no  calculi 

remain  in  the  neck  of  the  gall-blad- 
der or  the  cystic  duct  by  palpation 
with  a  finger  on  the  outside  and 
a  sound  in  the  lumen  of  the  duct. 
Unless  the  patient's  condition  for- 
bids, the  surgeon  should  then  explore 
the  common  duct  and  the  head  of 
the  pancreas,  while  the  gall-bladder 
is  temporarily  plugged  with  gauze. 
These  manipulations  are  described 
at  p.  932  (Choledochotomy).  When 
it  is  certain  that  no  stones  remain, 
a  purse-string  suture  of  catgut  is 
inserted  in  the  fundus  of  the  gall- 
bladder about  an  inch  from  the 
opening.  A  drainage  tube  open  on 
the  side  as  well  as  at  the  end,  or 
cut  in  fish-tail  fashion^  is  passed  into 
the  gall-bladder  for  about  an  inch, 
and  is  stitched  to  the  gall-bladder 
with  two  or  more  catgut  sutures. 
The  tube  is  then  pushed  into  the 
gall-bladder,  inverting  its  edges 
around  the  tube,  and  the  purse- 
string  suture  is  pulled  taut  and  tied.  With  this  valve-like  closure  of  the 
opening  the  biliary  fistula  does  not  remain  open  long  after  the  tube 
is  removed.  If  the  gall-bladder  cannot  be  inverted  in  this  manner  the 
opening  should  be  sutured  tightly  around  the  tube,  and  in  such  cases 
or  whenever  there  is  a  possibility  of  leakage  around  the  tube  it  is 

'■  It  is  convenient  to  have  this  tube  wrapped  in  gauze  and  the  gauze  again-  sur- 
rounded by  rubber  dam,  so  that  the  sutures  holding  it  to  the  gall-bh^dder  will  not 
tear  out. 


Fig.  894. — Cholecystostomy:  the  gall- 
bladder tube  is  surrounded  with  gauze 
from  a  cigarette  drain.  (Deaver  and 
Ashhurst.) 


CHOLECYSTOSTO.M  Y   AM)   ( 'IIOLFA ' YSTI'U  TOM  Y 


\YM 


safer  to  insert  alst)  a  small  cigarette  drain  Ix-sidc  the  gall-bladder 
(Fig.  S()4).  'I'lie  gauze  pads  are  tlieii  removed  and  the  alxlominal 
\v(»imd  is  closed  around  the  drainage.  The  tube  in  the  gall-hladder 
remains  until  it  I'omes  away  of  itself,  whieh  is  usu.dly  about  the  end 
of  the  second  week.  The  fistula  in  sueh  cases  ceases  to  discharge  bile 
\'ery  soon  after  the  tube  is  removed.  When  prolonged  drdlnnge  is 
desired,  as  in  cases  of  cholangeitis,  pancreatic  lymphangeitis,  etc., 
the  gall-bladder  should  not  be  iincrted  around  the  tube,  but  should 
be  closed  tightly  around  it  without  inversion  of  its  wall;  then  the 
gall-bladder  should  be  sutured  to  the  parietal  peritoneum,  or  even  to 
the  anterior  sheath  of  the  rectus  muscle;  and  biliary  drainage  should 
j)ersist  for  from  four  to  six  weeks  at  the  least.  In  some  cases  of  pan- 
creatic disease  many  months  are  required  before  it  will  be  safe  to 
allow  the  fistula  to  close. 


Fig.  895. — Cholecystectomy:  the  cy.stic  duct  and  the  cystic  vessels  have  been  cUiiiipcd 
and  Hgated,  and  the  gall-bladder  is  being  enucleated  from  its  bed  under  the  liver.  The 
method  of  suturing  the  peritoneal  folds  is  indicated.     (Deaver  and  Ashhurst.) 


Cholecystectomy. — After  exposure  and  isolation  of  the  parts  in 
the  usual  way,  the  cystic  duct  is  identified,  and  the  peritoneum  over- 
lying it  is  incised,  and  is  separated  from  the  cystic  duct  by  gauze 
dissection  until  the  common  duct  is  reached.    The  cystic  duct  is  then 


932     OPERATIONS  ON   THE  GALL-BLADDER  AND  JilLE-DUCTS 

grasped  with  two  hemostatic  forceps  and  is  divided  l^etween  them. 
The  cystic  artery  and  vein  which  He  above  and  to  the  inner  side  of  the 
duct  are  then  clamped  with  two  hemostats  and  divided  l^etween. 
The  cystic  vessels  may  be  ligated  now  or  later.  The  gall-bladder 
is  then  enucleated  from  its  attachments  to  the  liver,  leaving  a  peri- 
toneal fold  on  each  side  (Fig.  895).  When  the  gall-bladder  has  been 
removed  these  peritoneal  folds  are  sutured  together;  but  if  there  is 
much  bleeding  from  the  denuded  liver  surface,  or  in  cases  of  marked 
infection,  it  is  safer  to  put  a  cigarette  drain  in  the  bed  of  the  gall- 
bladder and  suture  the  peritoneal  folds  over  it. 

If  on  opening  the  abdomen  the  surgeon  encounters  very  dense 
adhesions,  it  may  not  be  practicable  to  proceed  as  above  indicated. 
In  such  cases  Terrier's  operation  (1905)  is  to  be  preferred:  the  anterior 
margin  of  the  liver  is  identified,  and  the  fundus  of  the  gall-bladder 
found.  The  gall-bladder  is  opened  at  its  fundus  and  its  lower  wall  is 
cut  open  little  by  little  by  snipping  with  fine  scissors.  This  incision 
is  continued  into  and  through  the  cysticus,  right  down  to  the  chole- 
dochus.  The  splitting  of  the  cystic  duct  is  the  most  difficult  part  of 
the  operation,  because  it  cannot  be  distinguished  from  the  outside, 
on  account  of  adhesions,  and  it  is  only  by  following  its  lumen,  as 
one  follows  the  strictured  lumen  of  the  urethra  in  external  perineal 
urethrotomy  without  a  guide,  that  the  choledochus  can  be  reached. 

Before  concluding  the  operation  of  cholecystectomy,  the  common 
and  hepatic  ducts  should  be  sounded,  through  the  stump  of  the  cystic 
duct,  to  make  certain  that  no  calculi  have  been  overlooked.  A  drain- 
age tube  is  then  passed  into  the  stump  of  the  cysticus,  and  up  the 
hepaticus  for  about  1  cm.,  and  is  stitched  in  position  with  No.  0 
chromic  catgut.  The  subhepatic  space  should  also  be  drained  b}'  a 
tube,  and  these  two  tubes  must  be  carefully  distinguished  (by  color, 
by  insertion  of  two  safety  pins  instead  of  one,  or  in  some  other  way), 
so  that  no  subsequent  confusion  can  arise.  The  abdominal  wound 
is  then  closed  around  the  drainage.  The  tube  to  the  subhepatic  space 
may  be  removed  on  the  second  or  third  day,  but  that  which  drains 
the  hepaticus  should  be  allowed  to  remain  at  least  for  two  weeks.  If 
there  has  been  much  hemorrhage  or  escape  of  bile  into  the  subhepatic 
space  it  is  safer  to  use  a  glass  tube  for  drainage  of  this  region.  This 
tube  is  replaced  by  a  rubber  tube  within  a  few  days,  and  the  subse- 
quent treatment  conducted  as  when  a  glass  tube  has  been  used  to 
drain  the  pelvis  (p.  S62). 

Choledochotomy  and  Choledochostomy  are  employed  interchange- 
ably as  are  the  corresponding  terms  relating  to  the  gall-bladder,  since 
at  present  almost  every  operation  involving  an  incision  into  the  chole- 
dochus is  supplemented  by  drainage  of  that  structure.  When  the 
gall-bladder  is  present  it  serves  as  a  guide  to  the  common  duct,  which 
is  brought  into  the  wound,  when  possible,  by  the  method  noted  at 
p.  929,  after  the  gall-bladder  has  been  opened  and  cleared  of  stones 
as  previously  described.  The  common  duct  often  is  much  dilated 
and  it  may  be  difficult  to  distinguish  it  from  the  portal  vein.     For 


CllOLKDOClKnOMY  933 

this  purpose  a  liypodermic  iuhmIIc  may  he  used,  as  advised  by  Terrier 
and  l>y  1  )eaver.  The  index  fiiijj;cr  is  passed  into  the  foramen  of  \Vinsh)\v, 
while  the  thumb  is  plaeed  on  the  free  horder  of  the  j^astrohepatic 
omentum  and  the  supraduodenal  portion  of  the  choledoehus  is  pal- 
pated. If  a  stone  is  found  it  searcely  ever  is  j)ossihle  to  push  it  haek 
through  the  eystieus  into  the  irall-hladder,  l)ut  sometimes  the  seoop 
or  forceps  may  be  passed  down  from  the  gall-bladder  through  the 
eystieus  for  removal  of  the  stone.  In  most  cases,  however,  it  is  neces- 
sary to  incise  the  duct  over  the  stone  to  extract  it.  This  incision  is 
made  in  the  long  axis  of  the  duct  and  of  convenient  length.  If  the 
duct  is  large  enough  the  finger  makes  the  best  probe  to  search  for  other 
stones.  Any  stones  detected  bv  finger  or  scoop  or  sound,  should  l)e 
pushed  toward  the  opening  in  the  choledoehus;  if  impacted  in  the 
retroduodenal  portion  of  the  duct  a  stone  may  be  crushed  between  the 
fingers  or  broken  up  by  the  scoop,  and  the  fragments  extracted  from 
the  incision  in  the  supraduodenal  portion  or  pushed  into  the  duodenum 
through  the  ampulla  of  \'ater.  As  a  last  resort  relroduodenal  chole- 
dochofomy  may  be  necessary;  or  if  a  calculus  is  impacted  in  the  lower 
end  of  the  common  duct  very  close  to  the  duodenum,  transduodenal 
choledochotomy  may  be  necessary.  These  operations  are  described 
below. 

"When  all  stones  have  been  removed,  the  common  duct  is  drained 
by  passing  a  rubber  tube  large  enough  to  fill  its  lumen  up  toward 
the  hepatic  duct  for  1  to  2  cm.  (Hepaticus  drainage,  Kehr's  operation.) 
The  tube  is  fixed  in  the  common  duct,  as  described  in  connection 
with  cholecystectomy;  and  the  gall-bladder  is  drained  by  a  separate 
tube.  (If  cholecystectomv  is  necessarv  the  stump  of  the  eystieus  may 
be  closed  with  suture).  The  operation  is  concluded  by  drainage  of 
the  subhepatic  space,  as  after  cholecystectomy. 

In  cases  ivhere  the  gall-bladder  is  absent,  choledochotomy  may  be 
a  very  diflficult  operation  if  many  adhesions  are  present,  as  there  is 
no  guide  to  its  location.  In  such  cases  Desjardins  recommends  that 
the  surgeon  commence  by  exposing  the  retroduodenal  portion  of  the 
choledoehus  by  mobilization  of  the  duodenum,  as  described  below. 
Or  the  surgeon  may  open  the  duodenum  and  identify  the  choledoehus 
by  retrograde  catheterism  through  the  ampulla  of  Vater.  I  believe 
the  former  method  is  preferable. 

Retroduodenal  Choledochotomy. — If  an  incision  is  made  through  the 
parietal  peritoneum  on  the  right  of  the  descending  duodenum,  this 
coil  of  intestine  may  be  separated  by  blunt  dissection  from  the  posterior 
abdominal  wall,  and  restored  to  the  condition  it  occupied  in  fetal  life. 
By  turning  the  duodenal  loop  to  the  left  {mobilization  of  the  duodenum, 
Jourdan,  1895)  the  head  of  the  pancreas  and  the  retroduodenal  por- 
tion of  the  common  duct  are  brought  into  view  (Fig.  896),  and  an 
impacted  calculus  may  be  removed  by  direct  incision  (Fig.  897) .  As 
in  most  cases  in  which  this  operation  is  necessary  the  supraduodenal 
portion  of  the  choledoehus  has  already  been  opened,  this  may  be  used 
for  drainage,  and  the  incision  in  its  retroduodenal  portion  sutured.    It 


1»;U      OI'EHATIOXS   OS    THE   CALL^BLADDER   AXD   JilLE-DUCTS 

is  wise,  h()\ve\er,  to  k>a\'e  a  drain  in  tlic  retroduodenal  s])ac(',  for  fear 
of  leakage. 

Transduodenal  Choledochotomy  (McBurney,  ISOI)  is  ap])licable  to  a 
calculus  iin])acted  in  the  aniijulla  of  Vater  or  very  close  to  the  duo- 
denal wall.  The  duodenum  is  opened  through  its  anterior  wall,  and 
the  bile  pai)illa  identified.  If  a  calculus  is  caught  in  the  ampulla 
it  usually  is  possible  to  extract  it  by  dilating  or  incising  the  paj)illa. 


Fig.  896. — Retroduodenal  choledochot- 
omy: after  mobilization  of  the  duodenum, 
a  stone  is  exposed  at  the  site  of  obstruc- 
tion to  the  sound.    (Deaver  and  Ashhurst.) 


Fig  897. — Retroduodenal  choledochot- 
omy: the  choledochus  is  incised  over  the 
impacted  calculus.  (Deaver  and  Ash- 
hurst.) 


If  it  is  impacted  in  the  common  duct  just  outside  the  duodenal  wall, 
it  is  necessary  to  inci.se  also  the  posterior  wall  of  the  duodenum  over 
the  calculus,  and  then  to  open  the  choledochus  and  remo\e  the  stone. 
The  opening  in  the  choledochus  is  then  sutured  to  the  incision  in  the 
posterior  duodenal  wall,  to  ensure  adequate  drainage  of  the  chole- 
dochus; this  is  Kocher's  operation  of  diiodeno-choledochostomy  (1895). 
The  incision  in  the  anterior  wall  of  the  duodenum  is  then  sutured  as 
any  intestinal  wound,  and  the  abdominal  incision  is  closed  in  the 
usual  way. 

Cholecystenterostomy. — The  anastomosis  may  be  made  with  the 
duodenum  (cholecysto-duodenostomy)  or  with  the  stomach  (chole- 
cysto-gastrostomy).  A  lateral  anastomosis,  about  an  inch  long,  by 
suture  (p.  834),  is  the  best  method,  but  if  it  is  impossible  to  apply 
rubber-covered  clamps  to  prevent  fecal  extravasation  during  the 
operation,  a  small  sized  Murphy  button  may  be  used  for  the  anasto- 
mosis. 


A  XO.M  AUKS   or  SIIAI'E   AM)   roSIT/OX 


935 


SURGERY    OF    THE    LIVER. 


Anomalies  of  Shape  and  Position.  Kx(ri)t  in  rare  cases  of  con- 
genital, <liai)lira<:niatic,  or  unil)ili(;il  hernia  the  position  of  the  Hver 
seldom  is  altered  unless  hepatoptosis  (fallinj^;  of  the  liver)  exists  in  con- 
nection with  visceroptosis  (p.  898).  Apart  from  rather  vague  pains 
hei)atoptosis  produces  no  characteristic  symptoms  and  the  diagnosis 
nnist  he  made  hy  recognition  of  tiie  li^■er  in  its  abnormal  j)osition. 
Usually  it  descends  somewhat  toward  the  median  line,  and  is  recognized 
as  a  large  tumor  to  the  right  of  the  umbilicus  of  the  size  and  con- 
sistency of  the  liver;  often  a  notch  can  be  felt.  When  displaced 
there  is  resonance  over  the  normal  site  of  the  liver  dulness,  and 
pulmonary  resonance  and  intestinal  tympany  may  merge.  It  is 
distinguished  from  a  movable  or  enlarged  kidney  by  the  absence  of 
urinary  symptoms,  by  the  fact  that  the  liver  moves  in  respiration, 
while  the  kidney  does  not,  and  that  it  lies  in  front  of  the  colon,  not 
l)ehind  it. 

Treatment. — Treatment  should  consist  in  reposition  of  the  liver, 
when  this  is  possible,  with  the  patient  recumbent,  and  the  applica- 
tion of  an  abdominal  belt  as  in  cases  of  pendulous  abdomen  fFig. 
<S7o).  If  palliati^"e  treatment  proves  ineffective,  the  abdomen  may 
be  opened  and  the  anterior  margin  of  the  liver  stitched  to  the  costal 
border,  with  mattress  sutures  of  heavy  chromic  catgut. 

Changes  in  the  Shape  of  the  Liver  usually  are  acquired,  and  are  of  two 
main  varieties.  In  one,  the  so-called  corset  liver  (Fig.  S9S),  the  plastic 
liver  has  become  indented 
by  compression  through  the 
costal  margin.  This  tends  to 
distort  the  cystic  duct,  caus- 
ing stagnation  of  bile,  with 
its  consequences  already  dis- 
cussed (p.  922).  In  the  other 
form  the  anterior  margin  of 
the  liver  is  drawn  down  in  a 
tongue  -  shaped  protrusion, 
known  as  linguifonn  or  Riedel's 
lobe  (1888).  Usually  disease 
of  the  biliary  tract  exists  and 
has  produced  the  deformity 
by  gradual  traction  from  ad- 
hesions or  the  weight  of  an 
enlarged  gall-bladder.  Treat- 
ment involves  operative  cure 
of  the  biliary  lesion,  after 
which  the  enlarged  lobe  usu- 
ally shrinks  (Terrier) ;  in  rare  instances  amputation  of  the  lobe  may 
be  desirable. 


y 


Fig.  ^9(S. — Corset  livtr,  from  a  patient  aged 
fifty-seven  jears.  Death  from  perforation  of  a 
malignant  ulcer  of  the  stomach.  (.See  Fig.  849.) 
Episcopal  Hospital.    (Deaver  and  Ashhurst.) 


930  SURGERY  OF   THE  LIVER 

Suppurative  Hepatitis. — There  are  three  main  \arieties  of  siippiira- 
tiou  wliicli  occur  in  tlie  Hver:  (1)  Abscess  the  result  of  trauma;  (2j 
pyemic  or  embohc  abscess;  and  (3)  tropical  or  amebic  abscess. 

1.  Traumatic  Abscess  is  rare;  it  may  occur  as  the  result  of  a  pene- 
trating wound,  or  from  secondary  infection  (through  tjie  blood  or 
bile)  of  a  hematoma  which  has  resulted  from  subcapsular  rupture 
(p.  841),  usually  is  single  and  may  be  of  large  size.  The  diagnosis 
depends  on  the  history  of  the  case,  and  development  of  symp- 
toms of  pus  formation;  and  the  treatment  is  the  same  as  for  tropical 
abscess. 

2.  Pyemic  or  Embolic  Abscess,  when  of  surgical  interest,  almost 
invariably  is  the  result  (»f  infection  through  the  portal  circulation,  and 
is  termed  suppurative  pylephlebitis.  Especially  frequent  as  causes 
are  appendicitis  and  typhoid  fever,  but  any  infection  in  the  distribu- 
tion of  the  portal  vein  may  be  the  cause;  and  cases  of  suppurative 
cholangeitis  involving  the  finer  intrahepatic  bile-ducts  often  cannot 
be  distinguished  either  during  life  or  at  autopsy  from  cases  of  suppu- 
rative hepatitis  caused  by  hematogenous  infection.  When  occurring 
from  appendicitis  or  other  acute  infection  the  symptoms  (pain,  high 
but  irregular  fever,  chills,  sweats,  tenderness,  and  enlargement  of  the 
liver,  sometimes  jaundice)  usually  develop  within  a  week  or  two  of 
the  primary  affection.  In  such  cases  the  liver  is  riddled  with  abscesses 
of  various  size,  and  operative  treatment  is  out  of  the  question.  Every 
such  case  is  fatal.  When  resulting  from  t\'phoid  fever,  however,  and, 
according  to  Quenu  and  Mathieu  (1911),  occasionally  as  the  result 
of  appendicitis,  the  symptoms  do  not  appear  until  convalescence  is 
established.  The  average  fever-free  interval  in  typhoid  fever,  according 
to  Melchior  (1910),  is  fourteen  days.  Such  cases  resemble  somewhat 
amebic  abscess,  and  treatment  is  the  same. 

3.  Tropical  or  Amebic  Abscess  takes  its  name  from  its  occurrence 
especially  in  the  tropics,  and  as  the  result  of  infection  with  the  Amoeba 
coli.  The  patient  usually  gives  a  history  of  residence  in  tropical  or 
semi-tropical  climes,  and  almost  always  has  suffered  from  dysentery; 
but  as  the  symptoms  of  amebic  colitis  sometimes  are  very  insignificant 
(p.  896)  too  much  faith  should  not  be  put  in  the  patient's  history. 
The  hepatic  abscess,  which  usually  is  single  (in  60  per  cent,  of  cases) 
and  of  large  size,  may  not  develop  or  at  least  may  not  begin  to  produce 
symptoms  until  many  years  after  the  occurrence  of  the  primary 
infection.  The  ameba  is  transported  to  the  liver  through  the  portal 
circulation,  and  the  destructive  process  begins  in  the  hepatic  cells. 
The  abscess  usually  is  in  the  right  lobe  of  the  li^-er,  but  even  when 
the  abscess  is  very  large  the  shape  of  the  liver  may  not  be  noticeably 
altered.  The  abscess  develops  silently,  like  a  cold  abscess,  and  it 
often  produces  no  symptoms  until  secondary  infection  has  occurred. 
^Mien  uninfected  by  pyogenic  organisms  the  contents  are  reddish 
brown  in  color  and  vary  in  consistence  from  fluid  to  gelatino-us. 
Amebfe  often  cannot  be  found  except  in  scrapings  from  the  wall  of  the 
abscess,  or  after  it  has  been  discharging  for  several  days. 


.sT/'/T/.'.t  7717';   IIEIW  TITIS 


\YXi 


St/mptonis.  Ill  niic-tliird  of  tlic  cases,  acconiiiif^  to  Uouis,  there 
are  no  symptoms  noticed  hy  the  patient  until  rupture  occurs,  usually 
into  the  lun<js,  pleura,  or  peritoneal  cavity.  When  symptoms  exist, 
they  may  not  he  referred  to  the  li\ cr  for  months  after  malaise,  lassitude, 
and  inereasin<:j  weakness  are  noted.  Jaundice  is  rare.  Wlien  local 
s_\inj)tonis  are  noted  tliey  frequently  are  referred  to  the  base  of  the 
ri^ht  hnifj  or  the  pleura.  Fever  is  anotlier  valuable  sign,  though 
the  tempeniture  may  not  be  high  except  in  the  evening;  in  malaria 
the  temj)erature  usually  rises  in  the  daytime.  Enlargement  of  the 
liver,  and  pain  (local  and  referred  to  the  right  shoulder)  may  not 
occur  until  late.  Diagnosis  is  aided  by  purging  the  patients  with 
salines  and  searching  the  stools  for  amebae,  which  usually  can  be  found 
in  the  third  or  fourth  watery  stool.  A  high  leukocyte  count  in  the 
afternoon  is  regarded  as  an  indication  of  the  presence  of  secondary 
infection.  The  most  common  mistakes  in  diagnosis  are  (1)  failure 
to  recognize  the  presence  of  disease  of  any  description;  (2)  misinter- 
pretation of  the  significance  and  nature  of  basic  pneumonia;  (3) 
attributing  the  fever  to  malaria;  and  (4)  mistaking  other  diseases  for 
abscess  of  the  liver,  and  vice  versa  (Manson,  1904).  In  tropical 
abscess  the  spleen  is  not  enlarged. 


Fk;.  899. — Transpleural  operation  for  abscess  of  the  liver:  a  portion  of  rib  has  been 
excised,  subperiosteally;  and  the  diaphragm  is  being  sutured  to  the  tissues  or  the  costo- 
phrenic  sinus.     (Deaver  and  Ashhurst.) 


Treatment. — Treatment  involves  drainage  of  the  abscess.  At  the 
same  time  proper  treatment  of  the  colitis  (p.  896)  must  be  instituted. 
The  operation  of  hepatotomy  for  drainage  of  a  liver  abscess  resembles 
that  for  subphrenic  abscess  (p.  814).  If  the  abscess  cannot  be  localized 
by  the  physical  signs,  laparotomy  should  be  done  and  its  position 
determined.  No  attempt  should  be  made  to  localize  the  abscess  by 
aspiration,  except  after  the  liver  has  been  exposed  to  view.  If  the 
abscess  is  found  to  be  near  the  convex  surface  of  the  liver  or  if  this 
fact  can  be  determined  without  opening  the  abdomen,  the  abscess 
should  be  drained  by  the  transpleural  route  (Knowsley  Thornton, 
1885)  as  in  the  operation  for  subphrenic  abscess:  Excise  (subperi- 
osteally) four  inches  of  the  eighth,  ninth  or  tenth  rib  in  the  mid-axillary 
line;  then  suture  the  diaphragm  to  the  tissues  of  the  costo-phrenic 


938 


SURGERY  OF   THE  LIVER 


sinus  (deej)  layer  of  costal  periosteum,  hoth  layers  of  ])leuraj,  without 
opening  the  pleura,  by  three  or  four  interrupted  sutures  of  chromic 
catgut  (P'ig.  N99).  Then  make  an  incision  along  the  upper  bonier  of 
the  next  lower  rib,  through  all  structures,  diaphragm  included,  until 
the  liver  is  exposed.  In  acute  cases  the  liver  is  bluish,  soft  and  pulpy, 
and  may  bulge  into  the  wound.  Adhesions  usually  shut  off  the  peri- 
toneal cavity,  but  it  is  well  tf)  isolate  the  parts  with  gaw/.e.  Where 
these  adhesions  are  the  densest,  usually  the  abscess  is  found.  It  is 
opened  b\-  a  stab  with  a  bistoury,  and  the  tract  enlarged  by  dressing 
forceps  followed  by  the  finger.  It  is  drained  by  a  double  tube  of  rubber, 
and  not  until  four  or  fi\e  days  at  least  have  elapsed  should  irrigation 
be  eniplo>ed.    The  sinus  may  take  man\"  weeks  to  close. 


Fig.  900. — Hepatic  abscess  exposed  by  flap  method.  Appendicostomy  for  accom- 
pan>-ing  colitis.  Catheter  in  the  appendix.  Recoverj'-  (Dr.  C.  H.  Frazier's  case.) 
Episcopal  Hospital. 


Echinococcus  Cyst. — Hydatid  cyst  is  the  result  of  infection  by  the 
Tenia  echinococcus,  a  parasite  found  in  the  intestinal  tract  of  dogs, 
sheep,  and  other  animals.  The  ova  enter  the  intestinal  tract  of  man 
with  food  or  drink,  or  possibly  as  the  result  of  handling  or  being  licked 
by  an  animal  infested  by  the  parasite.  The  capsule  is  digested  in  the 
intestinal  tract  of  the  patient,  and  the  embryo  is  liberated.  It  bores 
into  the  intestinal  wall,  and  in  most  ca.ses  is  carried  by  the  portal 
system  to  the  liver.  Hydatid  cysts  of  other  organs  or  tissues  are  rare 
and  often  secondary  to  a  primary  growth  in  the  liver.  After  the  para- 
site (in  larval  state)  reaches  the  liver,  it  loses  its  booklets  and  enters 
the  immature  or  cysticercus  stage.  Inflammatory  changes  cause  a 
connective  tissue  encapsulation,  so  that  the  cyst  wall  consists  of  two 
layers;  an  outer  laminated  layer  or  capsule,  and  an  inner  granular 
or  germinal  layer.  The  contents  are  clear,  colorless  fluid,  unless  sec- 
ondary infection  occurs,  when  the  fluid  is  purulent;  sometimes  it  is 
bloody  or  bile-stained.    Hydatid  fluid  contains  a  poisonous  ptomain, 


FAlllSOi'OCCVS  CYST 


\w 


which  iii;i\  cause  coiiN  iilsiciiis,  rapidity  of  the  |)iilse  and  respirations, 
dihited  ])iipils  and  e(>liaj>se.  I'liless  the  parasite  dies  (hmghter  cysts 
develop  within  tlie  original  [jarent  cyst.  'I'he  heads  or  scoliees  ot"  the 
})arasites  ding  to  the  germinal  layer  in  j)edunculated  \es»cles  known 
as  hrood  capsules.  These  are  similar  to  the  j)rimary  cyst.  The 
scoliees  may  become  detached  and  lie  free  in  the  hrood  capsule,  or  if 
this  ruptures  they  may  float  free  in  the  parent  cyst.  Degeneration, 
calcification,  and  death  of  the  parasites  may  occur.  Hydatid  cysts 
usually  occur  in  the  right  lobe  of  the  liver  and  in  90  per  cent,  of 
cases  the  c\st  is  solitary. 

Symptoms. — The  clinical  course  of  the  disease  much  resembles  that 
of  tropical  abscess'  of  the  liver.  So  long  as  secondary  infection  is 
absent,  and  until  the  cyst  grows  so  large  as  to  project  from  the  surface 
of  the  liver,  symptoms  are  inconspicuous.  The  average  duration  of 
the  disease  before  treatment  is  sought  is  from  five  to  seven  years. 
Attacks  of  urticaria  are  not  uncommon.  There  is  danger  of  rupture 
(spontaneous  or  from  trauma),  into  the  bile  passages,  the  peritoneal 
cavity,  the  gastro-intestinal  tract,  or  the  thorax;  as  well  as  from 
secondary  infection. 

Diagnosis. — The  diagnosis  can  be  made  only  when  a  palpable  cystic 
enlargement  of  the  liver  is  detected.  The  condition  must  be  dis- 
tinguished from  carcinoma  of  the  liver,  which  is  a  solid  growth,  and 
usually  secondary  to  a  tumor  elsewhere;  from  tropical  abscess  (p.  93(5); 
from  empyema  thoracis  and  subphrenic  abscess;  and  from  gummatous 
growths  (syphilitic)  of  the  liver,  which  are  much  more  common  in  this 
country  than  hydatid  cysts. 

Treatment. — There  is  no  cure  without  operation 
downward  and  are  best  exposed  by  laparotomy, 
that  of   Quenu;  after  exposure  of  the 
cyst  its  contents  are  aspirated  by  means 
of  a  veri/fine  trocar  and  cannula.    It  is 
well  to  insert  the  trocar  through   the 
rubber  tube  used  to  drain  the  fluid  from 
the  cannula  (Fig.  901),  as  in  this  way  no 
dangerof  leakage  occurs.  Then  a  solution 
of  formalin  (1  per  cent.)  is  allowed  to  run 
into  the  cyst  cavity  and  to  distend  it. 
This  is  permitted   to  remain   for  five 
minutes  so  as  to  sterilize  its  contents. 
It  was  demonstrated  by  Deve  (1901) 
that  each   of  the  parasitic  elements  is 
capable    of    reproducing    the    primary 
lesion,  and   Quenu   found   (1902)   that 
formolization  as  above  described  steril- 
ized the  contents  of  the  cyst  absolutely.     The  cyst  is  then  emptied,  its 
wall  is  incised,  and  the  germinal  membrane  is  removed.     Then  the  cyst 
may  be  closed  by  sutures,  without  drainage,  but  it  should  be  attached 
to  the  abdominal  wound  so  that  an  intracvstic  effusion  of  bile  or  blood 


'SLost  cysts  grow 
The  best  plan  is 


Fig.  901. — Qucnu's  mothod  of 
formolization  of  hydatid  cysts  of 
the  liver. 


940  SURGERY  OF   THE  LIVER 

can  be  evacuated  easily  should  either  complication  occur  later.  If 
the  old  plan  of  marsui)ialization  (opening,  packing  with  gauze,  and 
suturing  to  the  abdominal  wound)  is  employed  without  formoliza- 
tion,  the  condition  is  analogous  to  that  of  a  cold  abscess  opened  and 
drained — secondary  infection  is  almost  unavoidable,  })iliary  effusion 
is  frequent,  and  tlie  sinus  takes  very  long  (months)  to  close. 

Cirrhosis  of  the  Liver. — Pathologists  distinguish  between  portal  cir- 
rhosis, in  which  the  cause  is  transmitted  by  the  portal  circulation,  and 
the  obtrusive  symptoms  are  those  of  portal  obstruction;  and  biliary 
cirrJiosis  in  which  the  essential  lesion  is  a  radicular  cholangeitis,  and 
the  conspicuous  clinical  feature  is  jaundice  (A.  O.  J.  Kelly).  The 
latter  has  not,  so  far,  become  amenable  to  surgical  treatment,  though 
proper  operative  treatment  of  diseases  of  the  gall-bladder  and  bile- 
ducts  may  often  prevent  its  development;  and  in  the  former  surgery 
is  able  only  to  modify  or  lessen  the  distressing  symptoms,  without  in 
any  way  bringing  about  a  cure  of  the  underlving  disease. 

The  main  symptoms  of  portal  cirrhosis  of  the  liver  are  (1)  gastro- 
intestinal hemorrhages,  from  obstruction  of  the  portal  vein,  and  (2) 
ascites  from  peritoneal  changes  which  accompany  the  disease.  Pure 
portal  obstruction  is  said  not  to  produce  ascites,  which  it  is  believed 
is  caused  almost  solely  by  changes  in  the  endothelium  of  the  peri- 
toneum; it  is  in  the  nature  of  a  chronic  serositis,  probably  due  to  the 
toxemia  of  disordered  hepatic  function.  Cases  of  portal  cirrhosis 
sometimes  are  complicated  by  tuberculosis  of  the  peritoneum,  or  by 
a  chronic  polyserositis  associated  with  cardiac  disease;  and  in  such 
cases  it  may  not  be  the  hepatic  toxemia,  but  the  complicating  disease 
which  is  responsible  for  the  peritoneal  effusion.  ]Most  of  the  operative 
methods  proposed  for  the  relief  of  ascites  are  based  on  the  idea  that 
this  occurs  as  a  direct  transudate  from  the  portal  system.  Such  is 
not  the  case,  and  a  rational  operation  must  seek  to  alter  the  nutrition 
of  the  peritoneal  endothelium;  operations  which  seek  to  establish 
a  collateral  circulation  for  the  obstructed  portal  system  are  rational 
only  when  gastro-intestinal  hemorrhages  are  present  or  threaten. 

Paracentesis. — The  ascitic  fluid  may  be  removed  by  repeated  tap- 
pings, and  in  rare  instances  the  fluid  finally  ceases  to  re-accumulate. 
The  trocar  and  cannula  should  be  thrust  into  the  abdomen  in  the  mid- 
line between  umbilicus  and  pubes,  after  it  has  been  ascertained  that 
the  bladder  is  empty.  Xo  anesthetic  is  necessary,  though  in  nervous 
patients  or  when  the  abdominal  wall  is  thick,  a  local  anesthetic  may  be 
used.  The  patient  should  be  in  the  semi-recumbent  position,  and  as 
the  fluid  is  evacuated  concentric  pressure  should  be  made  on  the  abdo- 
men by  means  of  a  many-tailed  bandage,  so  as  to  prevent  syncope 
by  the  sudden  relief  of  pressure  on  the  large  abdominal  bloodvessels. 
If  the  amount  of  fluid  is  very  great,  it  is  best  not  to  remove  all  of  it 
at  once.  The  puncture  is  sealed  with  collodion,  and  the  abdomen 
kept  tightly  bandaged,  in  an  effort  to  prevent  re-accumulation. 

Laparotomy  with  gauze  abrasion  of  the  serous  surfaces  of  the  liver, 
spleen,  and  diaphragm,  in  an  eft'ort  to  alter  their  nutrition,  and  check 


TUMORS  OF  1J\  Kh',  (;.\/.L  ni..\l)l)l'h\   AM)   lUI.E  DICTS      \)[\ 

the  f'oniiiitioii  ot"  tlie  ascitic  fluid,  which  is  simultaneously  cxacuatcd, 
is  a  more  eflectual  method  of  treatment,  and  mucli  ot"  tlie  good  attrib- 
uted to  e{)i])h)pexy  (see  beh)vv)  is  no  doubt  due  to  tliese  stei)S  which 
form  an  integral  j)art  of  that  oi)eration. 

Epiplopexy,  introduced  by  'J'alnia  (1SS<))  and  Aforison  (IS!)4),  con- 
sists in  suturing  the  omentum  to  the  parietal  i)eritoneum  on  both 
sides  of  the  abdominal  incision,  or  between  the  peritoneum  and  the 
posterior  sheath  of  the  rectus  muscle,  in  the  effort  to  establish  a 
collateral  circulation.  As  already  noted,  abrasion  of  the  serous 
surfaces  of  the  liver,  sj)leen,  dia})liragm,  and  of  the  parietal  j)erit()neum 
forms  an  integral  part  of  this  operation,  the  idea  being  that  a  collateral 
circulation  will  be  established  in  the  adhesions  thus  produced.  The 
surest  manner  of  establishing  a  collateral  circulation  for  portal  obstruc- 
tion is  to  make  an  anastomosis  between  the  portal  \'ein  and  \'ena 
cava  (Eck's  fistula);  this  was  done  by  Vidal  (1903)  in  a  patient  almost 
exsanguinated  by  gastro-intestinal  hemorrhages;  but  though  these 
were  cured,  the  ascites  was  not,  and  death  ensued  four  months  later 
from  acute  general  infection,  evidently  enterogenous;  the  portal 
blood-stream  had  been  short-circuited  and  the  liver  was  no  longer 
interposed  to  the  hordes  of  microbes  constantly  absorbed  from  the 
bowels. 

After  epiplopexy  the  abdomen  is  not  drained,  though  this  formerly 
was  considered  essential.  Symptomatic  relief  has  been  secured  in  from 
one-third  to  one-half  the  cases. 

Tumors  of  the  Liver,  Gall-bladder,  and  Bile  Ducts. — Benign  tumors 
are  very  rare  and  have  little  surgical  interest. 

Carcinoma  of  the  Liver  may  be  primary,  but  in  almost  all  cases  is 
secondary  to  a  growth  in  the  distribution  of  the  portal  system.  The 
usual  type,  whether  primary  or  secondary,  is  nodular  or  multiple 
carcinoma.  If  this  is  a  primary  growth  most  of  the  nodules  are  metas- 
tases from  one  original  focus  which  usually  is  in  or  near  the  gall- 
bladder (Beadles,  1896);  while  in  secondary  carcinoma  the  nodules 
are  scattered  all  over  the  liver  uniformly,  and  not  massed  about  the 
fossa  of  the  gall-bladder.  The  nodules  are  whitish,  gray,  or  yellowish 
masses,  from  the  size  of  a  pinhead  to  that  of  an  orange,  but  seldom 
larger  than  a  walnut.  They  stand  out  from  the  surface  of  the  Vner, 
frequently  cause  perihepatitis  with  resulting  adhesions;  and  when  large 
often  become  umbilicated  as  the  result  of  interstitial  hemorrhages. 
If  the  growth  is  primary,  gall-stones  usually  are  present. 

Syinytoms  are  not  characteristic,  and  the  diagnosis  rarely  is  made 
until  enlargement  of  the  liver,  with  palpable  nodules,  and  the  develop- 
ment of  ascites  and  sometimes  of  jaundice,  indicate  that  the  disease 
has  passed  the  operable  stage.  The  symptoms  of  the  secondary 
growth  in  the  liver  frequently  o\'ershadow  those  due  to  the  primary 
focus  in  pancreas,  stomach  or  intestinal  tract,  anfl  even  at  autopsy 
it  may  be  difficult  to  find  the  primary  growth. 

Treatment  in  almost  all  cases  must  be  palliative;  very  occasionally 
a  primary  growth  may  be  excised,  but  in  most  patients  the  prognosis 


942  SURGERY  OF   THE  LIVER 

is  hopeless,  and  death  ensues  in  from  fiAe  to  seven  months  after  recog- 
nition of  the  condition. 

Sarcoma  of  the  Liver  almost  always  is  secondary,  usually  to  a  growth 
in  the  eye  or  the  soft  tissues  of  the  limbs:  but  many  years  occasionally 
elapse  between  removal  of  the  primary  timior  and  evidence  of  hepatic 
involvement. 

Carcinoma  of  the  Gall-bladder  and  Bile-ducts  is  much  more  common 
than  carcinoma  of  the  liver.  Secondary  carcinoma  is  rare  and  of  little 
surgical  impr)rtance. 

Primary  Carcinoma  of  the  GaU-bladder  is  found  in  about  2  per  cent. 
of  specimens  removed  by  cholecystectomy;  and  almost  invariably 
gall-stones  are  present  and  are  regarded  as  the  predisposing  cause. 
The  growth  begins  at  the  fundus  or  near  the  neck  of  the  gall-bladder, 
and  extension  occurs  to  the  YneT.  The  early  symptoms  are  those  of 
cholelithiasis;  later  a  hard  noflular  tumor  of  the  gall-bladder  is  rec- 
ognized, but  by  this  time  hepatic  involvement  frequently  renders  the 
case  inoperable.  The  most  favorable  cases  are  those  where  a  thick- 
walled  gall-bladder  removed  at  oj>eration  is  discovered  to  be  the  seat 
of  carcinoma  only  when  microscopically  examined.  Such  patients 
may  survive  several  years,  whereas  those  in  whom  the  correct 
diagnosis  is  made  before  or  during  operation  usually  die  within  a 
year. 

Treatment  consists  in  extirpation  of  the  growth  whenever  possible. 
This  always  should  include  excision  of  the  entire  cystic  duct  with  the 
gall-bladder  and  may  necessitate  removal  of  the  adjoining  liver  tissue 
also.  [Methods  of  suture  of  the  liver  have  already  been  considered 
'  p.  ^43  . 

Primary  Carcinoma  of  the  Bile  Ducts  presents  much  the  same  symp- 
toms as  carcinoma  of  the  head  of  the  pancreas,  notably  obstructive 
jaundice,  of  slow  or  sudden  but  almost  always  painless  onset,  never 
remitting  but  gradually  deepening  to  a  bronze  or  almost  black  hue. 
If  the  growth  is  in  the  choledochus.  the  gall-bladder  becomes  dis- 
tended and  enlarged,  and  is  palpable  through  the  abdominal  wall  in 
half  of  the  cases.  If  the  growth  is  in  the  hepaticus  (which  is  rare), 
no  enlargement  of  the  gall-bladder  occurs.  Disturbance  of  the 
pancreatic  functions  indicates  obstruction  at  the  papilla  of  \'ater. 

Treatment. — Exploratory  operation  is  proper  in  all  but  manifestly 
hopeless  cases.  If  a  radical  operation  cannot  be  done,  the  abdomen 
should  he  closed  tcithout  doing  anything  further.  Palliative  operations 
for  malignant  obstruction  of  the  common  duct  have  a  very  high 
primary  mortality  (hemorrhage  from  cholemiaj  and  do  not  prolong 
the  patient's  life  nor  promote  his  comfort.  If  complete  extirpation 
can  be  done,  the  draiiaage  of  bile  into  the  intestine  must  be  restored 
by  some  form  of  biliary-intestinal  anastomosis  (p.  928).  Retro- 
durxlenal  resection  of  the  choledochus  in  1^  operations  collected  by 
Oppenheimer  (1912).  gave  an  immediate  m(»rtality  of  50  i>er  cent. 
Occasionally  a  growth  at  the  papilla  of  \'ater  can  be  excised  by  a 
transduodenal  operation  (Czerny.  1901).   The  immediate  mortality  of 


INFECTIONS  OF   THE  PANCREAS  943 

this  oiHTJitioii,  acfordiiig-  to  ()])iKMilR'iin('r,  is  oA  per  cent.  Tlic  most 
radical  oiHTatioii  of  all  for  ^Towths  at  the  lower  end  of  the  cliolcdochiis 
resembles  that  of  cei)halic  i)ancreutectomy  (p.  951). 

SURGERY    OF    THE  PANCREAS. 

Infections  of  the  Pancreas.  'J'heoretically  infection  may  reach  the 
pancreas,  as  it  may  any  other  organ,  (1)  through  the  blood-stream; 
(2)  along  its  excretory  ducts;  (3)  through  its  lymphatics;  or  (4)  by 
contiguity,  from  neigliboring  structures. 

1.  Iiifirtioti  ihroiKjh  the  blood  is  comparatively  rare.  The  pancreas 
is  seldom  affected  in  pyemia;  but  the  occurrence  of  pancreatitis  as  a 
complication  of  acute  parotitis  (mumps)  though  unusual  is  well 
recognized  (Deaver  and  Ashhurst  tabulate  01  cases);  and  a  few  cases 
of  in\()hement  of  the  ])ancreas  ha\e  been  reported  in  cases  of  scar- 
latina, influenza,  and  other  acute  infections.  In  chronic  interacinar 
pancreatitis,  also,  which  is  a  frequent  accompaniment  of  arterio- 
sclerosis and  which  usually  results  in  diabetes,  the  causative  agent 
is  conveyed  to  the  pancreas  in  the  blood-stream;  and  it  is  probable, 
as  pointed  out  below,  that  acute  pancreatitis  is  the  result  of  some 
toxin  which  exerts  its  action  first  on  the  endothelial  lining  of  the 
bloodvessels. 

2.  Infection  through  the  ducts  has  been  produced  experimentally 
by  injection  of  bile,  gastric  juice,  and  other  irritants,  resulting  in 
acute  inflammation;  but  it  is  not  probable  that  such  occurrences  are 
frequent  in  life,  though  Opie  recorded  a  case  in  which  a  small  gall- 
stone blocked  the  orifice  of  the  ampulla  of  Vater  and  allowed  retro- 
jection  of  bile  into  the  pancreatic  duct. 

3.  Infection  through  the  Lymphatics. — The  lymph  nodes  around 
the  head  of  the  pancreas  drain  the  lymph  from  the  gall-bladder  and 
bile-ducts,  as  well  as  (more  or  less  directly)  from  the  pylorus,  the 
appendix,  and  other  common  sites  of  intra-abdominal  infection.  The 
lymphatics  from  the  remainder  of  the  pancreas  are  more  or  less  inde- 
pendent of  those  about  its  head,  and  do  not  drain  such  common  sites 
of  infection  as  those  already  mentioned.  The  chronic  infections  of 
the  ])ancreas  are  almost  always  confined  to  the  head  of  the  gland,  and 
the  fibrous  tissue  which  forms  is  interlobular  in  distribution,  thus 
corresponding  to  the  lymphatic  tissue;  it  is  true  that  the  blood-chan- 
nels also  are  interlobular,  but  if  in  these  cases  of  chronic  pancreatitis 
the  infection  was  conveyed  by  the  blood-stream  the  entire  gland  should 
be  involved,  which  is  not  the  case  in  chronic  interlobular  pancreatitis, 
the  common  form;  though  it  is  the  case  in  the  rarer  interacinar  form, 
in  which,  as  already  indicated,  the  causative  agent  probably  is  blood- 
borne.  That  the  infection  does  not  originate  in  the  excretory  ducts, 
in  cases  of  interlobular  oancreatit's,  is  indicated  by  the  local  dis- 
tribution of  the  resulting  fibrosis,  which  is  neither  scattered  diflFusely 
throughout  the  gland,  as  are  the  ducts,  nor  yet  situated  close  about 
the  parenchyma  of  the  gland  in  the  portion  w^hich  is  affected.     It  is 


944  SURGERY  OF   THE   PANCREAS 

thus  evident,  as  pointed  out  by  Maugeret  (1908),  tliat  the  condition 
commences  as  a  pancreatic  lymphangeitis,  the  term  suggested  by 
Arnsperger  (1911),  and  adopted  by  Deaver  and  Pfeiffer  (1912),  who 
have  been  particularly  instrumental  in  securing  recognition  of  the 
disease  in  this  country. 

4.  Infection  by  contiguity  is  rare,  except  when  a  gastric  ulcer  or 
carcinoma  becomes  adherent  to  or  perforates  into  the  pancreas. 

Acute  Pancreatitis. — Acute  catarrhal  pancreatitis  is  of  little  impor- 
tance surgically;  it  may  accompany  acute  gastroduodenitis,  and 
catarrhal  cholangeitis,  aiding  in  producing  the  obstructive  jaundice 
which  is  the  common  expression  of  these  conditions.  Acute  paren- 
chymatous pancreatitis  is  classified  as  hemorrhagic,  suppurative,  and 
gangrenous  (Fitz,  1889),  terms  which  indicate  the  stage  of  the  disease. 
The  suppurative  and  gangrenous  stages  frequently  are  classed  as 
subacute  pancreatitis. 

Acute  Hemorrhagic  Pancreatitis  is  the  commonest  form  of  acute 
pancreatitis.  The  adjective  hemorrhagic  is  attributive,  not  qualify- 
ing; hemorrhagic  inflammation  may  occur  in  any  organ,  but  it  is 
especially  frequent,  and  the  hemorrhagic  tendency  is  especially  marked 
in  the  case  of  the  pancreas.  It  is  probable,  as  long  ago  indicated  by 
Truhart,  that  the  process  commences  as  an  autodigestion  of  the  pan- 
creas. It  is  true  that  under  normal  conditions  the  pancreatic  juice  is 
activated  by  a  kinase  with  which  it  comes  in  contact  only  after  leav- 
ing the  pancreas;  but  under  abnormal  conditions,  as  pointed  out  by 
Carnot  (190S),  a  kinase  may  be  generated  within  the  pancreas  itself 
by  the  action  of  leukocytes  or  bacteria  or  toxins.  These,  probably, 
are  conveyed  to  the  organ  through  the  blood-stream,  for  the  lesions 
in  acute  pancreatitis  are  scattered  here  and  there,  and  are  not  confined 
to  any  particular  segment  of  the  gland.  The  results  of  the  infection 
are  caused  by  extravasation  of  the  pancreatic  juice,  whether  this  is  con- 
fined to  the  pancreas  itself  or  escapes  into  the  retroperitoneal  tissues  or 
into  the  free  peritoneal  cavity:  the  tryj)sin  causes  hemorrhages  and 
the  steapsin  causes  areas  of  fat  necrosis. 

The  disease  is  more  frequent  in  men  than  in  women,  and  most 
patients  are  of  middle  or  later  life,  and  rather  obese.  Recurring  slight 
attacks  are  not  very  rare,  though  the  surgeon  often  is  not  consulted 
until  a  fulminating  attack  occurs,  and  so  far  the  existence  of  the  dis- 
ease in  milder  forms  has  scarcely  ever  been  recognized.  Trauma 
has  in  some  cases  seemed  a  predisposing  cause;  in  them  a  hematoma 
probably  had  formed ,  and  only  when  it  ruptured  and  allowed  extrava- 
sation of  pancreatic  juice,  did  the  symptoms  of  acute  pancreatitis 
arise.  If  the  abdomen  is  opened  very  early  in  the  attack  there  may 
be  nothing  to  indicate  the  pancreas  as  the  seat  of  disease;  after  the 
lapse  of  a  few  hours,  liowever,  there  is  found  a  sero-purulent  exudate 
usually  blood-tinged  and  areas  of  fat  necrosis  in  the  omentum,  mes- 
entery, or  peripancreatic  fat.  Hematomas  may  be  observed  in  the 
same  situations.  The  areas  of  fat  necrosis  occur  as  minute  whitish 
specks  or  flakes,  dense  and  rigid,  often  surrounded  by  a  hemorrhagic 


ACl'TE   I'.\.\<  h'h'A  77 77,s'  04.") 

zone,  tuul  nut  raised  I'rom  the  surl'ucc  of  the  surrouiuJing  fat,  a  fact 
wliieh  aids  in  distinguishing  them  from  mihary  tubercles.  Disorgani- 
zation of  the  pancreas  occurs  very  early,  and  microscopical  study 
seldom  is  satisfactory,  a  fact  which  accounts  for  the  uncertainty  that 
still  exists  as  to  pathogenesis.  If  the  ])atient  lives,  gangrene  of  the 
pancreas  may  follow,  and  the  entire  lesser  peritoneal  cavity  may  be 
converted  into  an  abscess  containing  foul-smelling,  purulent,  chocolate 
cohered  exudate,  with  pieces  of  necrotic  pancreas  floating  around  loose 
in  the  fluid. 

Symptoms  and  Clinical  Course. — Usually  symptoms  arise  so  sud- 
denly and  are  of  such  an  overwhelming  nature  that  the  patient  can 
give  no  history  of  previous  milder  attacks.  In  most  cases  seen  by 
the  surgeon  the  disease  runs  its  course  in  from  fi\'e  to  eight  days, 
death  occurring  within  a  week,  unless  prom])t  operation  is  done. 
Pain,  vomiting,  and  collapse  are  the  most  prominent  symptoms.  The 
pain  is  intense,  excruciating,  and  may  cause  collapse;  it  is  neuralgic, 
and  colicky  in  nature,  and  resembles  that  due  to  acute  intestinal 
obstruction,  though  the  latter  often  begins  with  mere  twinges  and 
becomes  severe  only  after  the  lapse  of  hours.  The  pain  of  pancreatitis 
does  not  shift,  it  remains  epigastric.  Collapse  may  not  occur  until 
the  liemorrhagic  exudate  breaks  through  the  capsule  of  the  pancreas. 
\'omiting  is  so  frequently  repeated  that  it  resembles  that  which  occurs 
in  cases  of  intestinal  obstruction;  but  in  the  latter  the  vomiting  is 
projectile  and  regurgitant  and  there  is  little  or  no  nausea.  Hiccough 
is  frequent  and  ^•ery  persistent.  Dyspnea  is  said  to  be  present  rather 
often.  Physical  examination,  early  in  the  course  of  the  disease,  is 
unsatisfactory,  owing  to  tenderness  and  abdominal  distention.  ]\Ius- 
cular  rigidity  is  not  very  great.  After  the  subsidence  of  the  most  acute 
symptoms,  toward  the  third  or  fourth  day,  it  usually  is  possible  to 
detect  an  ill  defined  tumefaction  in  the  epigastrium,  and  there  fre- 
quently is  tenderness  and  perhaps  palpable  resistance  in  the  left  loin. 
The  patient  continues  to  be  gravely  ill;  the  stomach  is  unretentive; 
emaciation  is  rapid;  slight  jaundice  is  frequent;  the  pulse  is  weak 
and  running,  and  the  temperature  is  elevated  and  perhaps  hectic 
in  type.  The  patient  w^ill  now  die  of  exhaustion,  sepsis,  or  secondary 
peritonitis,  unless  promptly  relieved  by  operation. 

Diagnosis. — Acute  pancreatitis  must  be  distinguished  from  per- 
foration of  the  stomach  or  duodenum,  biliary  colic,  intestinal  obstruc- 
tion, appendicitis,  and  poisoning  by  drugs  which  have  been  swallowed. 
In  most  cases  which  might  be  confused  with  pancreatitis,  a  history  of 
the  affection  can  be  obtained  and  will  lead  to  a  correct  diagnosis. 
Acute  pancreatitis  is  the  disease  which  cannot  be  recognized  as  any 
other  affection  and  which  is  apt,  therefore,  to  pass  undiagnosed. 

Treatment. — ^The  abdomen  should  be  opened  promptly  for  purposes 
of  exploration,  by  an  epigastric  incision;  isolate  the  upper  abdomen 
by  gauze  packs ;  if  a  collection  of  fluid  is  found  in  the  lesser  peritoneal 
cavity,  evacuate  it  by  aspiration;  expose  the'  pancreas  (preferably 
through  the  gastro-colic  omentum),  and  if  it  presents  no  gross  lesions 
60 


946  SURGERY  OF   THE  PAXCREAS 

do  not  incise  it,  but  merely  tampon  the  lesser  peritoneal  cavity;  if 
there  is  an  abscess  or  hematoma  in  the  pancreas  incise  its  capsule,  and 
with  a  blunt  instrument  carry  the  incision  into  the  substance  of  the 
gland,  to  secure  drainage  of  all  pockets  of  pus,  etc.  Then  tampon 
the  incision  into  the  pancreas,  using  a  large  rubber  tube  for  drain- 
age in  the  centre  of  the  tampons.  In  some  cases,  especially  of 
subacute  pancreatitis,  a  counter-incision  in  the  left  loin  should  be 
made.  Complications  in  the  biliary  tract  (which  are  not  frequent) 
should  not  be  treated  at  this  time,  except  for  very  positive  indica- 
tions. 

Abscess  or  Gangrene  of  the  Pancreas  usually  is  a  sequel  of  acute 
pancreatitis.  The  recognition  of  the  condition  depends  upon  atten- 
tion to  the  clinical  course  of  the  disease,  and  the  detection  of  evidence 
of  deep-seated  tumefaction  in  the  region  of  the  pancreas.  The  abscess 
frequently  points  in  the  left  loin,  and  if  this  is  the  case,  it  should  be 
opened  in  this  place.  In  other  cases  an  epigastric  incision  is  made 
first,  and  the  upper  abdomen  is  explored,  and  a  counter-opening  is 
made  wherever  it  seems  most  desirable.  Guinard  (1907)  commends 
the  thoracic  route  (left  side),  similar  to  that  employed  in  cases  of 
hepatic  or  subphrenic  abscess. 

Pancreatic  Fistula  sometimes  persists  for  a  long  time  after  an  opera- 
tion for  acute  pancreatitis.  The  discharge  is  exceedingly  irritating 
and  the  skin  should  be  protected  by  ointments  with  mineral  base. 
Antidiabetic  diet  should  be  insisted  upon,  as  advocated  by  Wolge- 
muth  (1912);  usually  the  discharge  decreases  rapidly  after  a  week  or 
ten  days,  and  the  fistula  then  closes. 

Chronic  Pancreatitis. — This  may  be  caiarrhal  or  interstitial  in  dis- 
tribution. The  former  is  believed  by  Mayo  Robson  and  others  to  be 
of  frequent  occurrence,  though  it  is  of  slight  surgical  significance; 
it  frequently  accompanies  chronic  interstitial  pancreatitis,  and  when 
duct-borne  infection  was  regarded  as  frequent  the  catarrhal  was 
believed  to  be  a  forerunner  of  the  interstitial  form.  Chronic  inter- 
stitial pancreatitis  occurs  in  two  main  forms:  interacinar  and  inter- 
lobular.  The  former  was  mentioned  at  p.  943,  as  accompanying 
arteriasclerotic  changes  in  the  pancreas;  the  lesions  involve  the  entire 
pancreas  (head,  body,  and  tail),  the  nutrition  of  the  islands  of  Langer- 
hans  is  affected  early,  and  diabetes  often  results.  It  is  not  amenable 
to  surgical  treatment. 

The  only  variety  of  this  disease  of  surgical  importance  is  chronic 
interlobular  pancreatitis.  As  already  pointed  out  this  begins  as  a 
pancreatic  lymphangeitis,  the  primary  focus  usually  being  in  the  gall- 
bladder or  ducts,  or  in  the  pyloric  region  of  the  stomach  or  duodenum. 
If  the  primary  focus  of  infection  can  be  recognized  and  properly 
treated  before  the  process  in  the  pancreas  has  advanced  to  the  stage 
of  organization  and  cicatrization  (true  chronic  interlobular  pancrea- 
titis), there  is  every  reason  to  believe  that  the  pancreas  will  not  be 
permanently  damaged.  The  disease  is  commonest  in  adult  males 
between  thirty  and  fifty  years  of  age. 


CHRONIC  PANCREATITIS  947 

Symptoms  and  Clinical  Course. — Tlie  symptoms  of  paiK-reatic  lym- 
phantioitis  are  those  of  the  causative  lesion,  and  the  local  pancreatic 
changes  are  not  recofjni/.ed  until  after  the  aixlomen  has  been  opened. 
Then  the  head  of  the  pancreas  is  found  eniarj^ed,  firmer  than  normal, 
and  the  individual  lobules  are  distinctly  ])alpal)le,  which  is  not  the 
case  in  the  normal  pancreas.  In  true  interlobular  pancreatitis,  the 
advanced  stage  of  i)ancreatic  lymphangeitis,  the  head  of  the  pancreas 
(the  body  and  tail  are  scarcely  ever  affected,  for  reasons  already 
pointed  out)  is  enlarged  and  hard  with  a  nodular  surface;  on  section, 
tense  bands  of  fibrous  tissue  traverse  the  cut  surfaces,  accounting 
for  the  formation  of  the  well-marked  lobules.  In  some  cases  the  en- 
largement of  the  head  of  the  organ  can  be  detected  through  the 
abdominal  walls.  The  symptoms  are  those  of  the  underlying  malady, 
accompanied  by  certain  additional  symptoms  and  physical  signs  and 
certain  changes  in  the  digestive  functions  which  characterize  the 
condition  as  one  of  pancreaiic  insufficiency.  Moreover,  whenever  the 
enlarged  head  of  the  pancreas  obstructs  the  common  bile  duct  (which 
traverses  it  in  two-thirds  of  cases),  there  are  added  sympt(mis  of 
hiliary  insufficiency,  namely,  obstructive  jaundice,  and  its  accompany- 
ing digestive  derangements.  The  consequences  of  -pancreatic  insuffi- 
ciency are  chiefly  steatorrhea,  and  azotorrhea: 

Steatorrhea  is  an  excess  of  fat  in  the  feces.  In  health  the  feces  con- 
tain about  20  per  cent,  of  fat,  which  represents  from  7  to  11  per  cent, 
of  the  fat  taken  as  food.  After  suppression  of  the  bile  alone  the  feces 
contain  (iO  per  cent,  of  fat;  after  suppression  of  the  pancreatic  secre- 
tion, 70  per  cent,  of  fat;  and  after  suppression  of  both  bile  and  pan- 
creatic juice  they  contain  90  per  cent,  of  fat  (Carnot).  Xot  only  is 
the  proportion  of  fat  in  the  feces  much  increased,  but  very  little  of  the 
ingested  fat  is  absorbed:  instead  of  only  about  one-tenth  being  unab- 
sorbed,  as  is  normally  the  case,  as  much  as  one-third  may  be  unab- 
sorbed  when  bile  is  absent  from  the  intestinal  canal,  and  when  both 
bile  and  pancreatic  juice  are  absent  90  per  cent,  of  the  ingested  fat 
may  be  recovered  from  the  feces.  Thus  where  both  bile  and  pancreatic 
juice  are  lacking  the  ingested  fat  is  used  hardly  at  all,  and  instead 
of  the  normal  chemical  changes  in  the  ingested  fat  (whereby  from 
35  to  40  per  cent,  of  it  is  converted  into  split  fats),  chemical  examina- 
tion of  the  feces  shows  that  split  fats  are  reduced  at  least  to  one-fifth 
of  normal  (R.  Gaultier,  1905).  It  is  seldom  that  excess  of  fat  in  the 
feces  is  visible  to  the  naked  eye.  In  well  marked  cases  of  steatorrhea 
the  passages  are  bulky,  of  a  silver,  gray,  or  asbestos-like  color,  and  the 
fat  may  float  on  the  surface  like  oil  droplets  or  particles  of  butter. 
But  such  stools  occasionally  occur  in  health  after  ingestion  of  large 
quantities  of  fatty  food;  and  in  slighter  degrees  steatorrhea  may  be 
caused  by  biliary  deficiency,  diarrhea,  and  other  intestinal  derange- 
ments, so  that  too  much  reliance  cannot  be  placed  on  it  as  an 
indication  of  pancreatic  insufficiency. 

Azotorrhea. — This  is  an  excess  in  the  feces  of  undigested  proteid 
material.    In  health  about  5  or  (i  per  cent,  of  the  nitrogen  ingested 


948  SURGERY  OF   THE  PANCREAS 

as  food  is  excreted  in  the  feces,  whereas  in  cases  of  pancreatic  disease 
various  investigators  have  recovered  from  the  feces  as  much  as  32, 
45,  and  even  70  per  cent,  of  the  ingested  nitrogen.  This  condition 
occurs,  according  to  Fitz,  only  when  there  is  extreme  diminution  of 
the  pancreatic  juice,  and  is  significant  only  when  gastric  digestion  is 
normal,  when  the  diet  contains  no  excess  of  meat,  and  when  there 
is  no  diarrhea.  Schmidt's  test  consists  in  determining  that  the  nuclei 
of  the  muscle  cells  of  the  ingested  meat  fibres  are  still  intact,  as  they 
are  digested  only  by  the  j)ancreatic  juice.  Salomons  test  depends  on 
the  fact  that  lecithin  is  present  in  unusual  quantities  in  the  feces  of 
patients  with  pancreatic  disease;  accordingly  if  such  patients  are  put 
on  an  egg  diet,  from  0.4  to  1.2  grams  of  lecithin  are  excreted  in  the 
feces  daily,  instead  of  0.1  gram  or  less,  which  is  the  normal. 

The  presence  of  stercobilin  in  the  feces  indicates  that  there  is  not 
complete  obstruction  to  the  discharge  of  bile  into  the  intestines.  In 
cases  of  obstructive  jaundice  due  to  chronic  pancreatitis  and  common 
duct  lithiasis  the  obstruction  is  rarely  absolute,  and  a  distinct  though 
often  subnormal  reaction  for  stercobilin  may  be  obtained:  but  in 
carcinoma  of  the  head  of  the  pancreas  it  is  entirely  absent  or  present 
only  in  very  faint  traces. 

Urinary  Changes. — As  already  noted  glycosuria  seldom  occurs  in 
interlobular  pancreatitis  and  when  present  in  this  condition  appears 
only  very  late  and  usually  indicates  an  incurable  lesion.  "  Alimentary 
Glycosuria'  (that  which  occurs  when  an  excess  of  sugar  is  ingested) 
is  much  more  apt  to  occur,  and  may  be  a  constant  phenomenon,  if 
there  is  serious  disease  of  the  pancreas  (Wille's  test).  In  interacinar 
pancreatitis  glycosuria  is  a  very  frequent  and  an  early  symptom,  but 
this  disease  is  not  amenable  to  surgical  treatment. 

A  "pancreatic  reaction"  in  the  urine  has  been  described  by  Cammidge, 
which  he  considers  of  very  great  value  in  the  diagnosis  of  pancreatic 
lesions.  The  reaction  consists  in  the  crystallization  from  the  urine  of 
an  unknown  substance,  possibly  a  pentose.  Some  of  those  who  have 
most  practical  experience  with  the  "improved  test"  of  Cammidge 
speak  favorably  of  its  diagnostic  value,  though  it  is  sometimes  present 
in  other  abdominal  diseases.  But  Deaver  and  Ashhurst  say,  "  In  our 
own  practice  we  have  gradually  come  to  regard  it  as  of  less  and  less 
value."  In  a  series  of  351  tests  made  by  Kinney  for  Deaver,  it  was 
found  that,  "  roughly  speaking,  in  all  the  cases  in  which  the  condition 
of  the  pancreas  was  determined  accurately  at  the  time  of  operation, 
this  supposedly  specific  pancreatic  reaction  was  obtained  only  about 
two  and  a  half  times  as  frequently  when  the  pancreas  was  affected 
as  when  it  was  not." 

Diagnosis  of  Chronic  Pancreatitis. — The  confidence  of  clinicians 
in  their  ability  to  diagnose  chronic  pancreatitis  corresponds  to  their 
faith  in  the  accuracy  and  reliability  of  the  various  tests  for  pancreatic 
function,  particularly  the  Cammidge  reaction.  The  pancreatitis, 
however,  is  to  be  regarded  as  a  complication  of  some  other  disease 
rather  than  as  an  independent  affection,  and  it  cannot  be  too  often 


p.wcREATic  cMjrij  949 

emphasized  that  tlic  ciirahle  stage  of  the  panereatic  afi'ection  vanishes 
when  tlie  1\  iiii)haii<;t'itie  iiihltratioii  and  edema  gi\e  i)hiee  to  an  inter- 
iohniar  selerosis  whieh  can  be  no  more  curable  tlian  chronic  nephritis 
or  cirrhosis  of  the  Hver. 

From  the  symi)toms  and  physical  signs,  locahzation  of  the  (Hsease 
to  the  pancreatico-Iie]jatic  region  ahnost  always  can  be  made,  but  in 
the  differentiation  of  chronic  pancreatitis  from  disease  of  the  bile 
ducts  there  always  is  a  large  amount  of  doubt  in  the  minds  of  those 
clinicians  whose  experience  with  the  Cammidge  reaction  has  been 
unsatisfactory  and  disappointing. 

Treatment. — This  may  ahnost  be  summarized  in  the  expression 
treat  the  cause.  In  most  cases  the  cause  is  in  the  gall-bladder  or  bile- 
ducts,  and  prolonged  drainage  of  the  biliary  tract  allows  subsidence 
of  the  pancreatic  swelling,  by  overcoming  the  focus  of  infection  to 
which  it  was  due.  It  is  not  an  uncommon  thing  for  a  biliary  fistula 
to  remain  open  for  months,  or  for  symptoms  to  recur  if  it  closes  too 
early,  in  cases  of  chronic  pancreatitis.  Mayo  Robson  and  some 
other  surgeons  prefer  to  adopt  cholecystenterostomy  (p.  934)  as  a 
primary  operation  in  such  cases;  but  it  seems  more  logical  to  attempt 
to  relieve  the  biliary  infection  which  is  present  by  external  rather 
than  by  intestinal  drainage.  The  gall-bladder  should  be  sutured  to  the 
parietal  peritoneum  or  the  anterior  sheath  of  the  rectus,  as  described 
at  p.  931,  and  the  resulting  fistula  should  be  kept  open  for  several 
months;  and  it  is  important  at  the  time  of  operation  to  make  sure  of 
the  patency  of  the  common  duct  by  passing  a  sound  through  it  into 
the  duodenum. 

In  some  cases  of  pancreatitis  no  primary  lesion,  not  even  a  slight 
one,  can  be  found  in  the  biliary  tract.  The  pyloric  region  of  the 
stomach  or  the  duodenum  may  then  be  the  focus  of  infection,  and  if 
this  is  determined  to  be  the  case,  such  lesions  should  receive  appro- 
priate treatment.  ^Yhen  no  other  lesion  can  be  discovered  ^'autrin 
advocates  attacking  the  pancreas  directly,  and  especially  urges  drain- 
age of  the  retropancreatic  tissues  after  exposing  this  region  by  mobili- 
zation of  the  duodenum  (p.  933). 

Pancreatic  Calculi. — These  are  of  such  rarity  and  so  seldom  produce 
recognizable  symptoms,  that  they  are  of  comparatively  slight  surgical 
importance.  The  pathogenesis  of  the  stones  is  similar  to  that  of  biliary 
calculi,  but  their  composition  is  very  different,  most  pancreatic  calculi 
being  formed  largely  of  calcium  carbonate  or  phosphate.  They  are 
not  crystalline,  usually  occur  in  large  numbers  strung  along  the  pan- 
creatic ducts  like  the  beads  of  a  chain,  and  are  faceted  only  on  their 
ends.  They  occur  five  times  as  often  in  men  as  in  women,  but  have 
been  diagnosed  during  life  in  very  few  recorded  instances.  There  may 
be  symptoms  of  coincident  (and  perhaps  causative)  biliary  disease, 
or  of  pancreatic  insufficiency;  and  as  the  calculi  are  impermeable  to 
the  a:-ray  it  might  be  possible  to  recognize  their  shadows  in  a  skia- 
graph; pancreatic  colic,  if  it  occurs,  can  scarcely  be  distinguished 
from  that  due  to  biliarv  disease. 


950  SURGERY  OF   THE  PANCREAS 

Treatment. — Link  (1911)  collected  six  operations  I'or  ))ancreatic 
calculi,  and  reported  a  seventh  operation  b>'  himself.  He  performed 
paiicreastostomy  (analogous  to  cholecystostomy)  drawing  the  tail 
of  the  pancreas  out  through  the  transverse  mesocolon,  splitting  the 
gland  longitudinally,  removing  the  calculi,  and  stitching  a  rubber 
drainage  tube  in  the  principal  duct.  The  fistula  was  still  open  several 
months  after  the  operation,  but  the  patient  w^as  in  good  health. 

Carcinoma. — Carcinoma  is  the  most  frequent  tumor  of  the  pancreas. 
It  affects  the  head  of  the  organ  in  more  than  half  the  cases,  corre- 
sponding thus  with  chronic  interlobular  pancreatitis,  though  there  is 
so  far  no  proof  that  the  latter  disease  is  an  etiological  factor  in  the 
production  of  carcinoma.  The  tumor  begins  as  a  very  small  localized 
growth,  usually  as  scirrhus,  and  sometimes  gives  metastases  to  the 
liver  before  it  grows  large  enough  to  be  readily  recognized;  hence  many 
cases  of  secondary  carcinoma  of  the  liver  are  considered  primary 
until  a  minute  primary  nodule  is  found  in  the  pancreas.  If  the  growth 
occurs  in  such  a  situation  as  to  block  the  excretory  duct  of  the  pan- 
creas and  to  occlude  the  comrnon  bile-duct  the  resemblance  to  other' 
causes  of  obstructive  jaundice  (common  duct  lithiasis,  chronic  pan- 
creatitis, tumors  or  strictures  of  the  choledochus)  is  very  close,  and 
differential  diagnosis  may  be  difficult.  In  most  cases,  however,  of 
malignant  obstruction  of  the  common  duct  the  gall-bladder  becomes 
enlarged  (Cuurvoisier's  Law,  p.  92()),  and  in  very  many  cases  can  be 
easily  recognized  through  the  abdominal  w^all  as  a  globular  tumor, 
moving  with  respiration,  and  continuous  with  the  liver  dulness  wdiich 
often  also  is  greater  than  normal. 

Symptoms  and  Diagnosis. — There  are  no  pathognomonic  symptoms. 
The  original  clinical  description,  given  by  Bard  and  Pic  (1S88)  (which 
comprised  steadily  increasing  jaundice,  enlargement  of  the  gall-bladder 
and  rajjid  emaciation) ,  constitutes  a  syndrome  or  group  of  s}'mptoms 
common  to  any  lesion  which  causes  obstruction  at  the  papilla  of 
Vater  (Fig.  902).  A  carcinoma  of  the  pancreas  may  grow  in  situations 
other  than  the  head  of  the  gland  without  producing  this  syndrome, 
and  various  other  conditions  may  cause  obstruction  at  the  papilla 
of  Vater  and  thus  give  rise  to  this  same  group  of  symptoms.  In  the 
typical  case  of  carcinoma  in  the  head  of  the  pancreas,  a  patient, 
usually  over  forty  years  old,  complains  for  an  indefinite  period  of 
vague  upper  abdominal  symptoms  having  no  localizing  character. 
Then  jaundice  appears  painlessly,  and  continuously  deepens;  the 
gall-bladder  enlarges,  and  the  patient  loses  weight  and  strength  very 
rapidly.  Pain  may  or  may  not  be  a  conspicuous  feature.  Fever 
usually  is  absent.  Jaundice  never  lessens,  but  continuously  grows 
deeper;  signs  of  pancreatic  insufficiency  are  present,  and  stercobilin 
is  persistently  absent  from  the  feces. 

When  the  abdomen  is  opened  and  the  pancreas  is  examined  directly 
by  sight  and  touch  it  often  is  impossible  to  differentiate  carcinoma  and 
pancreatitis.  In  most  cases  reliance  must  be  placed  on  the  clinical 
history  of  the  disease.    In  pancreatitis  the  usual  cause  is  biliary  infec- 


CARCINOMA 


951 


tioii,  wliifli  seldom  is  present  in  ejireinonia.  In  pancreatitis  there  are 
recnrrent  attacks  of  pain,  fe^•er,  janndice,  characteristic  of  stone  in 
the  common  ckict;  while  in  carcinoma  the  onset  is  insidious,  the  course 
of  tlie  disease  is  ciironic,  and  there  are  no  periods  of  remission,  in 
pancreatitis  tiic  ^all-hladder  is  contracted  and  frial)le,  and  usually  is 
surrounded  i)y  adhesions;  in  carcinoma  it  is  enlarged  and  distended, 
and  is  nuich  more  tough  and  resistant  than  in  cases  ^f  pancreatitis. 
Treatment. — Medical  treatment  is  the  only  palliative  treatment 
that  is  to  he  countenanced.  Puliiathe  operations  (cholecystostomy 
and  cholccystcntcrostomy  arc 
those  a\ailable)  neither  i)ro- 
long  the  patient's  life  nor 
promote  his  comfort,  and 
should  be  done  only  when 
there  is  a  probability  that 
the  condition  is  not  malig- 
nant, and  that  prolonged 
drainage  of  the  biliary  tract 
may  succeed  in  overcoming 
the  obstruction  of  the  com- 
mon duct.  Radical  operation, 
which  scarcely  ever  is  possi- 
ble, consists  in  excision  of  the 
head  of  the  pancreas  (cephalic 
pancreatectomy).  This  implies 
also  resection  of  the  descend- 
ing duodenum,  as  removal  of 
the  pancreas  jeopardizes  its 
blood-supply.  The  technique, 
which  has  been  systematized 
by  Desjardins  (1907)  and 
Sauve  (190S),  comprises  sec- 
tion of  the  pylorus,  mobiliza- 
tion of  the  duodenum,  section 
of  the  duodenum  on  the  right 
of  the  superior  mesenteric 
arterj^  division  of  the  pan- 
creas (well  beyond  the 
growth),  and  section  of  the 
common  bile-duct.  Then  it 
remains  to  reestablish  the  con- 
tinuity of  the  gastro-intestinal  tract  by  gastrojejunostomy;  to  implant 
the  choledochus  into  the  intestine  or  stomach;  and  finally  to  drain 
the  remaining  portion  of  the  pancreas  into  the  intestine  (pancreato- 
enterostomy, Coffey,  1909).  If  the  tumor  is  in  the  body  of  the 
pancreas,  the  organ  may  be  resected  and  its  two  ends  reunited,  as 
done  by  Finney;  or  if  the  tail  only  is  involved,  it  may  be  removed 
and  the  stump  closed. 


Fig.  902.  — •  Obstructive  jaundice:  enlarge- 
ment of  the  gall-bladder  and  liver,  probably 
from  carcinoma  of  the  head  of  the  pancreas. 
An  inoperable  case.  German  Hospital.  (Deaver 
and  Ashhurst.) 


952  SURGERY  OF   THE  PANCREAS 

Cysts  of  the  Pancreas. — These  are  classed  as  true  cysts  (those  due 
to  retention,  cystic  neoplasms,  hydatid  cysts,  etc.)  and  pseudu-cysts 
(cysts  which  arise  in  close  association  with  the  pancreas  and  involve 
it  secondarily).  Pseudo-cysts  are  more  frequent  than  true  cysts, 
and  usually  are  formed  by  effusions  which  result  from  abdominal 
injuries. 

The  affection  is  commonest  in  early  adult  life,  and  in  many  cases 
a  history  of  traumatism  can  be  obtained,  though  it  may  have  occurred 
several  years  previously.  The  existence  of  retention  cysts,  the  result 
of  occlusion  of  the  ducts  by  calculi  or  chronic  pancreatitis,  is  so  rare 
that  it  is  of  pathological  interest  only.  Cystic  new  growths  also  are 
rare,  whether  benign  or  malignant,  and  the  cysts  which  result  seldom 
are  large.  Traumatic  cysts  form  the  vast  majority  of  cases  seen  by. 
the  surgeon,  and  they  are  frequently  situated  in  the  lesser  peritoneal 
cavity,  having  only  secondary  connections  with  the  pancreas.  The 
contents  of  the  cyst  usually  are  light  brown,  being  tinged  by  the  l)]ood 
in  the  original  liematoma,  or  from  hemorrhage  into  the  cyst  at  a 
later  period;  and  examination  often  detects  the  presence  of  one  or 
more  of  the  pancreatic  ferments. 

Symptoms  and  Diagnosis. — Apart  from  rather  vague  digestive  symp- 
toms and  recurring  attacks  of  acute  epigastric  pain,  which  seldom 
are  entirely  absent,  there  is  little  on  which  to  base  a  diagnosis  until 
a  tumor  can  be  detected,  or  at  least  until  it  is  of  such  size  as  to  cause 
pressure  symptoms.  The  latter  comprise  gastric  symptoms,  with 
recurring  attacks  of  pain  and  vomiting;  jaundice  from  biliary  obstruc- 
tion; and  constipation  from  pressure  on  the  colon.  Symptoms  of 
pancreatic  insufficiency  are  rather  unusual.  The  tumor  which  finally 
develops  may  present  through  the  gastro-colic  omentum,  through  the 
gastro-hepatic  omentum,  or  heJow  the  transverse  colon.  The  relation  of 
the  stomach  and  colon  to  the  cyst  may  be  determined  by  percussion, 
after  distending  these  organs  with  air.  In  rare  cases  the  cyst  may 
grow  backward  into  either  flank.  Most  cysts  transmit  the  pulsations 
of  the  aorta,  but  this  ceases  when  the  patient  assumes  the  knee- 
chest  posture.  Disappearance  of  a  cyst  may  result  from  its  rupture 
into  the  intestinal  tract,  whereupon  large  quantities  of  saliva-like 
fluid  are  discharged  from  the  bowel;  usually  the  cyst  refills. 

Diagnosis. — A  pancreatic  cyst  must  be  distinguished  from  mesenteric 
and  omental  cysts;  from  kidney,  suprarenal  and  hepatic  cysts;  from  an 
enlarged  gall-bladder;  from  ovarian  cysts;  from  cysts  of  the  spleen;  and 
from  aneurysm  of  abdominal  aorta.  As  a  rule  the  history',  the  relation 
existing  between  the  stomach  and  colon  and  possibly  signs  of  pan- 
creatic insufficiency,  make  the  diagnosis  fairly  certain  in  most  cases. 

Treatment. — Operation  is  indicated,  as  there  is  no  hope  of  spon- 
taneous cure.  If  the  cyst  is  small  and  pedunculated  (which  is  rare) 
it  may  be  possible  to  extirpate  it  completely.  In  most  cases  mar- 
supialization must  be  done — the  cyst  being  evacuated  and  its  cavity 
being  drained  with  gauze  and  tube.  Closure  of  the  resulting  fistula 
may  be  accelerated  hy  adherence  to  an  antidiabetic  diet. 


GENEIx'M.   DIAdXOSIS  OF   MiDO.MIXM.    'I'l.MOh'S  9'h] 

SURGERY    OF    THE    SPLEEN. 

Mdst  of  the  conditions  which  are  of  surgical  interest  cause  an 
enlargement  of  the  spleen,  and  it  is  important  to  be  able  to  differentiate 
an  ciihiri;c(l  sj)lccii  from  other  abdominal  tumors. 

General  Diagnosis  of  Abdominal  Tumors.  Splenic  Tumors. — 'J'hese 
may  be  almost  of  any  size,  even  filling  the  greater  part  of  the 
ab(lonien.  In  most  cases,  however,  the  enlargement  is  greatest  on  the 
left  side,  and  the  spleen  unless  fixed  by  adhesions,  moves  with  respir- 
ation. The  enlarged  spleen  is  so  closely  applied  to  the  al)dominal 
wall  that  it  is  impossible  to  insinuate  the  hand  between  its  upper 
margin  and  the  costal  border;  it  has  a  sharp  inner  border  which  is 
almost  always  interrupted  by  one,  tw^o,  or  three  notches.  Splenic 
tumors  always  grow  forward;  they  ne^'er  produce  fulness  in  the  loin. 
The  dulness  on  percussion  extends  up  to  the  sixth  rib  or  higher  in 
the  mid-axillary  line.  The  colon  is  first  displaced  downward,  and  later 
lies  behind  the  enlarged  spleen,  so  that  any  resonance  due  to  it  will 
be  in  the  flank  or  loin.  In  many  cases  of  splenic  enlargement  the 
blood  examination  aids  in  making  a  diagnosis. 

Kidney  Tumors  rarely  come  into  close  contact  wdth  the  anterior 
abdominal  wall,  and  even  when  they  do,  they  also  cause  marked 
bulging  in  the  loin.  They  have  a  rounded  contour,  wdth  no  sharp, 
notched  anterior  border.  The  range  of  motion  is  much  less  than  in 
the  case  of  the  spleen,  and  the  tumor  does  not  move  with  respiration. 
In  all  but  the  very  largest  tumors  the  hand  can  be  insinuated  between 
the  costal  margin  and  the  upper  border  of  the  kidney.  The  descending 
colon  overlies  the  anterior  surface  of  the  kidney  and  is  pushed  forward 
w^hen  the  kidney  enlarges.  Thus  there  is  resonance  anterior  to  the 
tumor  and  dulness  in  the  loin,  which  is  the  reverse  of  what  is  present 
in  the  case  of  a  tumor  of  the  spleen.  Other  important  differential 
signs  are  obtained  by  cystoscopy,  catheterization  of  the  ureters,  and 
examination  of  the  urine. 

Suprarenal  Growths  give  much  the  same  physical  signs  as  kidney 
tumors,  but  the  colon  often  is  pushed  downward  instead  of  forward. 
Hematuria  is  frequently  present. 

Periphrenic  Abscess,  apart  from  evidences  of  suppuration,  resembles 
enlargement  of  the  kidney  rather  than  splenic  tumor. 

Ovarian  Tumors. — In  the  case  of  a  wandering  spleen  of  nearly  normal 
size,  which  has  become  fixed  in  the  pelvis,  confusion  might  arise  unless 
a  distinct  notch  could  be  felt.  In  other  cases  ovarian  and  splenic 
tumors  could  scarcely  be  confused.  The  upper  border  of  an  ovarian 
tumor  is  very  seldom  in  actual  contact  with  the  left  costal  margin  unless 
it  reaches  also  to  the  right  costal  margin.  Ovarian  tumors  grow 
upward  from  the  pelvis;  they  do  not  move  with  respiration;  and  have 
no  sharp  border  with  one  or  more  notches.  They  extend  further 
across  the  middle  line  and  cause  more  symmetrical  enlargement  of 
the  abdomen.  Vaginal  examination  shows  the  tumor  in  close  associa- 
tion with  a  normal  sized  uterus,  and  frequently  the  pedicle  of  the  cyst 


954  SURGERY  OF   THE  SPLEEN 

can  be  felt  through  the  rectum.  There  is  usually  an  area  of  resonance 
between  the  upper  border  of  dulness  over  an  ovarian  tumor  and  the 
normal  area  of  splenic  dulness. 

Growths  of  the  Colon  at  the  Splenic  Flexure.  Alost  of  these  tumors 
cause  intestinal  obstruction  before  a  palpable  tumor  develops,  but 
occasionally  a  diffuse  non-obstructing  carcinoma  occurs  which  may 
have  to  be  differentiated  from  an  atypical  enlargement  of  the  spleen. 
A  tumor  of  the  colon  has  not  the  definite  shape  of  an  enlarged  spleen, 
nor  has  it  the  same  close  apposition  to  the  abdominal  wall  throughout 
its  extent.  It  usually  is  dull  to  superficial  and  resonant  to  deep  per- 
cussion. It  seldon  moves  much  during  respiration,  but  unless  fixed 
by  adhesions  changes  its  position  to  a  marked  extent  with  changes  in 
the  patient's  posture.  Sooner  or  later  intestinal  obstruction  and  metas- 
tasis develop,  but  exploratory  laparotomy  should  be  done  before  this 
stage  is  reached. 

Tuberculous  Peritonitis. — In  this  condition,  already  studied  in  Chap- 
ter XXII,  tumors  of  various  sizes  and  shapes  may  form  in  the  abdomen, 
and  one  which  forms  in  the  left  hypochondrium,  particularly  if  adherent 
to  the  spleen,  may  closely  simulate  a  splenic  tumor.  But  the  range 
of  motion  is  limited  by  adhesions,  and  although  the  anterior  border 
of  such  a  mass  may  feel  (juite  sharp  and  well  defined,  it  seldom  ex- 
hibits a  notch  similar  to  those  on  the  spleen.  ]\Ioreo\er,  other  foci  of 
tuberculosis  often  can  be  detected,  and  the  tuberculin  test  may  be  of 
value. 

Retroperitoneal  Tumors  are  comparatively  rare.  The  least  unusual 
variety  is  a  diffuse  lipoma,  which  is  clinically  semi-malignant,  tending 
to  recur  after  partial  extirpation.  Complete  extirpation  is  not  possible. 
Sarcoma  also  occurs  as  a  retroperitoneal  tumor,  usually  arising  in 
the  lymph  nodes.  These  retroperitoneal  tumors  usually  present  within 
the  circle  formed  by  the  large  bowel,  offering  to  percussion  a  dull  note 
surrounded  by  intestinal  tympany.  Inflation  of  the  stomach  and 
colon,  and  exmination  in  the  Trendelenburg  and  knee-chest  positions 
should  be  employed  in  obscure  cases. 

Causes  of  Enlargement  of  the  Spleen. — There  are  two  groups  of 
cases  associated  with  splenomegaly:  (1)  Those  in  which  the  blood 
changes  are  distinctive  (which  include  most  cases  of  malaria,  the 
leukemias,  pernicious  anemia,  splenomegalic  polycythemia,  typhoid 
fever,  and  kala-azar).  (2)  Those  in  which  they  are  not  distinctive. 
A  positive  diagnosis  cannot  be  made  without  a  blood  examination. 
With  the  exception  of  certain  cases  of  malaria,  splenectomy  is  ahsohitely 
coniraindicated  in  cases  included  in  the  firs^  of  these  two  groups.  In  the 
second  group  (no  characteristic  blood  changes)  are  included. 

1.  Cases  in  which  splenectomy  may  be  necessary  (moN-able  spleen, 
cysts,  tumors,  tuberculosis,  abscess,  Banti's  disease). 

2.  Cases  in  which  splenectomy  is  contraindicated  (congestion,  infarct 
and  thrombosis,  infectious  fever,  Hodgkin's  disease,  cases  of  portal 
obstruction,  amyloid  disease,  pseudo-leukemia,  hereditary  and  family 
forms  of  splenomegaly,  etc.). 


liANTl'S   DISEASE  955 

Movable  Spleen.  Tliis  occurs  oftcncst  in  women,  as  in  the 
somewhat  anak)gous  condition  of  hej)atoptosis,  already  described. 
Increased  weiglit,  from  enhirgement,  prediposes  the  spleen  to  ptosis, 
but  in  many  cases  t)f  enlarged  spleen  adhesions  hold  the  organ  in 
plaee.  A  mo\al)le  spleen  is  of  surgical  importance  chiefly  because 
of  the  accidents  to  which  it  is  subject,  notably  (iciite  torsion  of  its 
pedicle.  This  is  aecompanied  by  paroxysmal  pain,  with  reflex  vomit- 
ing, shook,  and  perhaps  by  the  later  development  of  gangrene  of  the 
spleen  and  peritonitis.  In  chronic  t(>rsio)i  the  twist  of  the  j)C(licle  is 
tight  enough  only  to  cause  congestion  of  the  spleen  which  leads  to 
perisplenic  adhesions.  Kecurrent  acute  attacks  may  lead  to  the 
same  results,  and  the  spleen  may  become  fixed  in  an  abnormal  position, 
a  condition  described  as  dislocated  spleen. 

Diagnosis.  The  diagnosis  of  a  movable  spleen  is  made  by  recogniz- 
ing in  the  movable  tumor  the  size,  consistency,  and  shape  of  the 
normal  spleen,  and  by  the  possibility  of  the  reduction  of  the  spleen 
to  its  normal  position  when  the  patient  is  recumbent.  The  diagnosis 
of  a  dislocated  spleen  is  difficult,  owing  to  the  adhesions  which  obscure 
its  shape. 

Treatment. — If  no  symptoms  are  produced  it  is  sufficient  for  the 
patient  to  wear  an  abdominal  support  which  will  tend  to  keep  the 
spleen  in  place.  In  most  cases  where  symptoms  are  present,  splenec- 
tomy is  indicated.     Splenopexy  does  not  give  satisfactory  results. 

Cysts  of  the  Spleen. — Hydatid  cysts  are  extremely  rare.  By  far 
the  greater  number  of  splenic  cysts  are  non-parasitic  in  type,  and 
most  are  the  result  of  traumatism,  though  lymphangeiomatous  and 
sequestration  cysts  may  occur,  as  well  as  cystic  degenerations  following 
embolism. 

Symptoms. — The  symptoms  are  those  usual  in  cases  of  splenomegaly 
and  the  diagnosis  depends  on  recognition  of  the  cystic  character  of 
the  enlargement. 

Treatment. — The  most  satisfactory  treatment  is  splenectomy. 

Abscess  of  the  Spleen  may  occur  in  pyemia,  but  cases  of  surgical 
interest  usually  develop  in  the  course  of  some  infectious  fever,  espe- 
cially malaria,  and  rarely  typhoid,  dysentery,  influenza,  and  dengue. 
These  abscesses  usually  are  single  and  of  large  size.  The  diagnosis 
depends  on  recognition  of  enlargement  of  the  spleen  with  general  and 
local  signs  of  suppuration.  Treatment  usually  must  be  confined  to 
incision  and  drainage,  since  perisplenic  adhesions  render  splenectomy 
difficult  or  impossible. 

Splenic  Anemia,  or  Banti's  Disease,  described  by  Banti  in  1888, 
is  characterized  by  great  chronicity  and  three  definite  clinical  and 
pathological  stages:  (1)  SimpAe  enlargement  of  the  spleen.  (2)  Enlarge- 
ment with  secondary  anemia.  (.3)  Cirrhosis  of  the  liver  with  spleno- 
megaly. The  cause  of  the  disease  is  unknown,  but  it  is  believed  to 
be  infectious  in  origin.  The  great  majority  of  cases  begin  in  early 
adult  life,  and  the  sexes  are  about  equally  affected.  The  disease 
extends  over  a  period  of  from  five  to  twenty-five  years,  and  always 
terminates  fatally  unless  the  spleen  is  removed. 


956  SURGERY  OF   THE  SPLEEX 

Pathology. — The  spleen  enlarges  steadily  but  retains  its  normal 
sha])f.  The  average  weight  is  from  150U  to  1750  grams.  Usually 
numerous  and  dense  perisplenic  adhesions  develop,  and  the  capsule 
and  fibrous  trabecule  of  the  spleen  undergo  hypertntphy,  but  the 
most  notable  change  is  hyperplasia  of  the  reticular  fibres  without 
any  marked  change  in  the  cellular  elements.  The  ^lalpighian  cor- 
puscles are  overgrown  with  connective  tissue,  and  there  is  prolifera- 
tion of  the  endothelium  it  the  sinuses.  Often  fairly  normal  areas  of 
the  splenic  tissue  remain  in  certain  places.  The  amount  of  endothelial 
proliferation  may  be  so  great  as  to  cause  the  characteristic  change 
known  as  Primitive  Endothelioma  of  the  Type  of  Gaucher.  The  splenic 
vein  is  always  more  or  less  sclerosed,  and  this  change  may  also  affect 
the  portal  vein.  Cirrhosis  of  the  liver  does  not  develop  until  late 
in  the  second  stage  of  the  disease,  and  from  this  time  on  the  changes 
cannot  be  distinguished  from  those  of  Laennec's  atropic  cirrhosis. 

Symptoms  and  Diagnosis. — The,^r^  stage  (simple  enlargement  of  the 
spleeU)  de^"elops  insidiously  and  lasts  a  long  time.  There  is  enlarge- 
ment of  the  spleen  which  may  not  be  discovered  until  it  is  of  great 
size,  but  no  other  symptoms  exist.  In  the  second  stage  there  are  added 
to  the  splenic  enlargement  symptoms  of  anemia  (pallor,  weakness, 
dyspnea,  palpitation).  The  anemia  is  of  the  chlorotic  type — diminu- 
tion of  red  blood  cells  and  hemoglobin  with  a  low  color  index.  There 
is  also  leukopenia  with  relative  lymphoc\i:osis.  But  the  symptoms 
of  anemia  may  be  out  of  all  proportion  to  the  blood  changes.  The 
amomit  of  urine  is  decreased,  and  it  contains  urobilin  and  albumin 
intermittently.  Finally  the  hver  begins  to  enlarge,  and  subsequently 
or  even  pre\'ious  to  palpable  enlargement  of  the  liver,  gastro-intestinal 
hemorrhages  particularly  hematemesis)  occur.  This  second  stage 
of  the  disease  lasts  from  eighteen  months  to  several  years.  With 
the  approach  of  the  third  stage  the  liver  diminishes  in  size,  ascites 
develops,  the  hemorrhages  increase,*  the  urine  is  still  further  diminished 
and  contains  urobilin  and  at  times  bilirubin,  the  skin  develops  pig- 
mentation and  sometimes  toward  the  end  of  the  disease  true  jaundice 
occurs. 

^luch  dispute  as  to  minor  points  still  exists,  but  the  above  descrip- 
tion gives  the  essentials  of  the  clinical  course  of  the  disease.  The 
diagnosis  usually  is  impossible  in  the  first  stage,  which  often  is  classed 
as  "idiopathic  splenomegaly."  Even  after  the  appearance  of  anemia 
differential  diagnosis  may  be  difficult.  In  cirrhosis  of  the  liver  gastro- 
intestinal hemorrhages  and  ascites  with  decrease  in  size  of  the  hver 
usually  appear  before  enlargement  of  the  spleen.  In  pernicious  anemia 
the  anemia  is  greater  than  in  Banti's  disease,  the  color  index  is  high, 
and  nucleated  red  blood  cells  and  poikiloc\-tes  are  present.  In  Banti's 
disease  the  hemoglobin  seldom  is  below  40  per  cent,  unless  there  has 
been  a  recent  severe  hemorrhage,  as  in  Morris  Lewis's  case.  In  malarial 
splenomegaly  the  parasite  usually  can  be  found  in  the  blood,  the  history 
of  the  case  is  different,  and  quinine  may  be  curative.  Leukemia  is 
disclosed  by  the  blood  examination.     Splenomegaly  in  childhood  (Fig. 


SI'lJCMCCntMY 


\):u 


903)  is  very  dillicult  to  (listiii^^uisli  from  Haiiti's  disease.  Some  of  tlie 
eases  prohahiy  are  Haiiti's  disease.  'Die  pseudojcithcniia  iufautium  of 
von  Jaivseh  iisuallx'  a])i)ears  in  the  second  year  of  life,  is  characterized 
b}'  very  _ii;ra\e  anemia  (red  blood  cells,  1, ()()(),()()();  normoblasts;  poikilo- 
cytosis),  by  leukocytosis  (15,()(){)  to 
20,000)  and  lymphocytosis.  There  is 
marked  si)lenonu>yaly  and  usually 
moderate  enlargement  of  the  liver. 
Banti's  disease  must  also  be  distin- 
guished from  syphilitic  s-plenomcgahi, 
amyloid  spleen,  and  horn  fa  mil  y  types 
of  splenomegaly  in  childhood.  Hemo- 
lytic splenomegaly,  recently  described 
by  Banti,  which  resembles  both 
Banti's  disease  and  hemolytic  jaun- 
dice, is  cured  promptly  by  splenec- 
tomy. 

Treatment. — The  only  treatment 
which  has  any  effect  on  the  disease 
is  removal  of  the  spleen,  and  this  is 
effective  only  if  done  before  cirrhosis 
of  the  liver  (third  stage  of  disease) 
develops.  The  presence  of  slight 
ascites,  with  enlargement  of  the  liver, 
which  occurs  in  the  end  of  the  second 
stage  of  the  disease  is  not  a  contra- 
indication to  splenectomy,  as  these 
symptoms  do  not  indicate  irremedi- 
able changes  in  the  liver.  The  immediate  mortality  of  splenectomy 
is  lowest  in  the  first  stage  of  the  disease,  and  increases  the  longer 
the  operation  is  postponed.  The  average  immediate  mortality  is  about 
25  per  cent. ;  permanent  cure  results  in  almost  all  cases  where  oper- 
ation is  done  in  the  first  stage,  in  from  50  to  75  per  cent,  of  those  in 
the  second  stage,  and  in  few  or  no  cases  in  the  third  stage. 

Splenectomy. — The  best  incision  is  one  on  the  left  corresponding  to 
Czerny's  gall-bladder  incision  (Fig.  (S92).  If  no  adhesions  are  present 
the  operation  is  not  difficult.  The  most  important  point  is  the  control 
of  hemorrhage.  The  capsule  of  the  spleen  and  the  veins  in  its  pedicle 
are  easily  torn.  It  is  best  if  possible  to  separate  adhesions  first,  and 
to  cut  the  lienophrenic  ligament  and  then  rotate  the  spleen  toward 
the  mid-line.  If  the  hand  can  be  introduced  gently  between  the  spleen 
and  diaphragm,  the  former  may  be  drawn  down  into  the  wound. 
If  the  vessels  in  the  pedicle  are  not  too  large  they  should  be  clamped 
close  to  the  spleen,  and  the  spleen  removed  after  cutting  between  the 
clamps  and  the  spleen.  In  some  cases  the  tail  of  the  pancreas  is  cut 
oft"  also  (i\Iayo),  but  if  carefully  sutured  no  fistula  will  result.  Unless 
there  is  enough  tissue  left  in  the  pedicle  for  the  safe  application  of 
ligatures  it  is  best  to  leaA'e  the  clamps  in  place  for  several  days.  In 
most  cases  it  is  well  to  leave  a  gauze  drain  in  the  wound. 


Fig.  903. — Splenomegaly  in  a  child 
aged  three  and  a  half  years.  (Dr. 
Newlin's  case.)  Pennsylvania  Hos- 
pital. 


CHAPTER  XXV 

SURGERY  OF  THE  BLADDER  AND  KIDNEYS. 

Genito-ueixary  surgery  has  been  developed  into  such  a  specialty 
of  late  years  that  it  is  impossible  in  a  text -book  such  as  this  to  do  more 
than  indicate  in  the  briefest  possible  manner  the  general  principles 
of  diagnosis  and  treatment  of  most  of  the  affections,  and  to  describe 
in  somewhat  greater  detail,  but  by  no  means  at  full  length,  those 
conditions  of  common  occurrence  which  are  constantly  encountered 
in  general  practice. 

GENERAL  DIAGNOSIS    OF   URINARY  DISORDERS. 

The  surgeon  must  study  the  urine  or  other  secretions  discharged 
from  the  urethra,  and  examine  the  genito-tirinary  organs  themselves.  A 
thorough  examination  includes  macroscopical  and  microscopical  study 
of  urethral  discharges  (both  those  which  are  apparent,  and  those 
obtained  after  stripping  the  prostate  and  seminal  vesicles,  p.  1013); 
chemical  and  microscopical  study  of  the  urine,  which  should  be 
collected  in  three  glasses  for  macroscopical  inspection ;  instrumentation 
with  soimd  or  catheter;  and  cystoscopic  examination.  In  many  cases 
bacteriological  study  of  the  urine,  pus,  etc.,  also  is  necessary. 


Fig.  904. — 1,  soft  rubber  catheter.       2,  metal  catheter. 

Catheters. — Catheters  are  hollow  tubes  designed  to  draw  off  the  con- 
tents of  the  bladder  (Fig.  904).  If  they  are  of  metal  (usually  nickel- 
plated)  they  must  have  a  curve  corresponding  to  that  of  the  urethra. 
Sir  Henry  Thompson's  instruments  were  curved  at  the  point  through 
an  arc  which  corresponds  to  the  fourth  of  the  circumference  of  a  circle 
whose  diameter  is  three  and  one-quarter  inches.  Flexible  catheters 
have  no  fixed  curve;  they  are  of  two  principal  kinds:  the  soft  rubber 
catheter  (Xelaton's),  and  the  English  catheter.  The  latter  is  made 
of  webbing  and  is  covered  with  shellac.  It  is  provided  with  a  stylet, 
and  when  used  with  th's  in  place,  is  fairly  rigid;  or  if  used  without  the 


GENERAL  DIAGNOSIS  OF   URINARY  DISORDERS  959 

stylet,  as  is  safer  and  eiistoinary,  may  he  made  to  retain  any  eurve  for 
a  short  time  by  mouldinfj  it  in  warm  water  and  tlien  quiekiy  phniging 
it  into  cold  water  wlien  it  becomes  stiti'.  A  catheter  should  be  ten  or 
eleven  indies  long,  and  i)rovided  with  one  or  two  large,  smoothly 
finished  eyes  Tiear  its  vesical  extremity;  all  catheters  sliould  1)6  solid 
from  the  eye  to  the  point,  thus  leaving  no  i)ocket  for  the  accumula- 
tion of  decomposing  blood  or  inspissated  pus.  An  English  catheter 
sliould  have  the  eye  woven  in  its  manufacture,  not  punched  out  after 
the  catheter  has  been  made;  and  if  used  with  the  stylet,  great  care 
must  be  taken  not  to  have  the  stylet  so  long  that  there  is  danger  of  its 
protruding  from  the  eye.  The  calibre  of  urethral  instruments  usually 
is  based  on  the  French  scale,  which  gives  the  diameter  in  thirds  of  a 
millimeter  (practically  tlie  circumference  in  millimeters).  The  sizes 
in  common  use  range  from  10  to  40;  the  average  adult  urethra  accom- 
modates a  sound  of  from  30  to  32  Fr.  A  rigid  instrument  smaller  than 
Xo.  10  is  dangerous  and  should  not  be  used. 

Introduction  of  the  Catheter. — The  greatest  damage  may  be  inflicted 
from  neglect  of  proper  antiseptic  and  aseptic  precautions.  [Metallic 
and  soft  rubber  instruments  may  be  boiled  just  before  use;  but  as 
webbing  instruments  will  be  ruined  by  heat,  they  should  be  soaked  in 
a  5  per  cent,  solution  of  formalin  (cold)  for  twenty  minutes  and  before 
being  used  should  be  rinsed  in  cold  sterile  water,  as  the  formalin  solu- 
tion might  cause  urethritis.  The  patient  should  be  lying  down; 
and  the  surgeon  after  washing  his  own  hands  (and  wearing  gloves  if 
possil)le)  should  retract  the  patient's  foreskin,  and  w^ash  the  glans  well 
with  soap  and  water  and  rinse  it  in  alcohol.  The  instrument  should 
be  well  lubricated  with  some  sterile  oil,  such  as  a  preparation  of  Irish 
moss,  or  glycerin;  and  it  often  is  well  to  distend  the  urethra  by  inject- 
ing the  lubricant  directly  into  it  from  a  sjTinge.  A  soft  catheter  is 
introduced  by  inserting  its  point  in  the  meatus  and  gently  pushing 
it  onward  into  the  bladder  little  by  little,  always  holding  it  close  to 
the  glans  penis.  A  metallic  instrument  is  most  easily  inserted  while 
the  surgeon  stands  at  the  patient's  left.  After  raising  the  penis  in  the 
left  hand  the  surgeon  gently  inserts  the  tip  of  the  instrument  within 
the  meatus,  while  its  shaft  lies  along  the  left  groin.  Then  without 
raising  the  shaft  from  the  plane  of  the  body,  it  is  carried  over  to  the 
mid-line,  as  the  tip  of  the  instrument  sinks  into  the  penile  urethra; 
it  should  enter  by  its  own  weight  and  should  not  be  forced.  Not 
until  the  point  has  reached  the  bulbous  urethra  should  the  handle 
be  raised  from  the  patient's  abdomen.  As  the  handle  is  gently  raised 
the  point  glides  under  the  pubis,  traverses  the  prostate,  and  enters 
the  bladder  (Fig.  905).  If  the  handle  is  raised  too  soon  the  point 
will  catch  in  front  of  the  triangular  ligament.  When  the  point  has 
successfully  passed  this  region,  and  the  handle  of  the  instrument  is 
nearly  vertical,  the  left  hand  may  be  placed  on  the  convexity  of  the 
instrument,  in  the  perineum,  and  thus  guide  it  into  the  bladder. 
When  the  catheter  has  entered  the  bladder  it  can  be  rotated  freely  in 
the  urethra,  on  its  own  axis,  and  its  shaft  lies  between  the  patient's 


960 


SURGERY  OF   THE  BLADDER  AND   KIDNEYS 


thighs  making  an  angle  of  45°  or  less  with  the  horizon.  An  instrument 
may  also  be  passed  from  the  patient's  right  side  by  the  manoeuvre 
known  as  the  tour  de  maitre:  the  instrument  is  introduced  with  its 
convexity  upward,  and  as  its  point  reaches  the  bulb  the  shaft  is 
swept  around  toward  the  abdomen,  and  is  raised  to  the  vertical  and 
then  depressed  between  the  patient's  thighs  as  the  instrument  enters 
the  bladder. 


Fig.  905. — Method  of  introducing  a  metal  catheter. 

Cystoscopes. — A  cystoscope  is  an  instrument  designed  to  permit 
visual  inspection  of  the  interior  of  the  bladder.  In  the  female  it  is 
possible  to  accomplish  this  by  direct  vision,  usingja  narrow  speculum 
(Kelly's  cystoscope)  and  placing  the  patient  in  the  knee-chest  or 
exaggerated  Trendelenburg  position  so  as  to  allow  the  bladder  to 
become  distended  with  air  so  soon  as  the  speculum  is  introduced.    In 


Fig.  906. — Illumination  of  anterior  vesical  wall  by  Xitze's  cystoscope.     (Park.) 


men,  however,  it  is  necessary  to  have  an  instrument  somewhat  resem- 
bling a  catheter,  provided  with  an  electric  light  at  its  vesical  extremity 
and  a  series  of  lenses  by  which  the  image  is  transferred  to  the  outer 
end  of  the  instrument  where  the  examiner's  eye  is  placed  (Fig.  906). 
In  most  cystoscopes,  the  system  of  lenses  reverses  the  image,  but  by 
inserting  another  lens,  the  image  may  be  righted  again;  this,  however, 


GENERAL    niAdXOSIS  OF   Ch'IXAh'Y   DISOliDEUS  001 

iiiiikos  tlie  ajjparatus  more  comijlitated  and  cuts  down  the  amount  ot" 
lifi;ht.  Cystoscopio  examination  requires  skill  and  practice,  and  should 
not  l)c  attempted  without  ample  training.  In  many  eases  it  may  he 
accomplished  alter  anesthetizing  the  deej)  urethra  with  a  4  jx'r  cent, 
solution  of  eucain,  hut  sometimes  a  general  anesthetic  is  required. 
Before  the  cystoscope  is  inserted  the  bladder  should  be  emptied  of 
urine,  and  irrigated  if  necessary  to  cleanse  it  of  blood  or  pus;  about 
four  ounces  of  solution  are  left  in  the  bladder.  Then  the  cystoscoj)e 
(sterilized  in  carbolic  acid  or  formalin  solution — it  cannot  be  boiled) 
is  introduced,  and  after  its  point  is  within  the  bladder,  the  electric 
current  is  turned  on,  and  the  examiner  proceeds  to  inspect  the  interior 
of  the  bladder.  The  ureteral  orifices  may  be  seen  and  the  swirl  of 
urine  discharged  from  each  may  be  readily  recognized,  as  also  the  dis- 
charge of  blood  or  pus  instead  of  urine.  The  condition  of  the  vesical 
mucous  membrane  is  also  studied;  foreign  bodies,  tumors  or  calculi 
are  searched  for;  the  presence  and  situation  of  the  orifices  of  diverticula 
are  located,  etc.  Some  cystoscopes  are  provided  with  slots  through 
which  a  fine  catheter  may  be  passed,  for  the  purpose  of  catheterizing 
the  ureters;  and  through  some  it  is  possible  to  insert  delicate  instru- 
ments and  under  the  control  of  vision  make  applications  to  ulcers, 
cauterize  or  snare  oft'  tumors,  remove  small  foreign  bodies,  etc.  An 
endoscope  is  an  instrument  similar  to  a  cystoscope,  but  designed  to 
examine  the  interior  of  the  urethra. 

Estimation  of  the  Functional  Capacity  of  the  Other  Kidney. — Always 
before  one  kidney  is  removed,  and  in  a  great  many  other  cases,  it  is 
necessary  for  the  surgeon  to  determine  the  functional  capacity  of  the 
healthy  (or  less  diseased)  kidne}'.  The  simplest  way  to  do  this  is  by 
chromoureteroscopy,  by  means  of  the  indigo-carmine  test;  this  was 
introduced  in  1903  by  Volcker  and  Joseph,  and  has  been  popularized 
in  this  country  by  B.  A.  Thomas:  20  c.c.  of  a  0.4  per  cent,  solution,  or 
4  c.c.  of  a  4  per  cent,  solution  of  indigo-carmine  are  injected  hypoder- 
mically,  and  a  cystoscope  is  introduced.  The  urine  is  stained  blue, 
and  if  the  kidney  is  healthy  the  stain  will  appear  in  the  urine  as  it  is 
discharged  from  the  ureter  of  the  kidney  in  question  Avithin  nine 
minutes  of  the  time  it  was  injected  hypodermically,  A  delay  of  more 
than  twenty  minutes  in  the  appearance  of  the  stain  indicates  serious 
incompetency. 

Other  methods  in\'olve  the  collection  of  urine  from  each  kidney 
separately.  This  is  best  accomplished  by  catheterization  of  the  ureters. 
Then  one  may  use,  in  addition  to  the  ordinary  chemical  and  micro- 
scopical tests  of  the  separate  urines,  also  what  is  known  as  the  yhenol- 
sidphonephthaJein  test,  which  is  highly  commended  by  H.  H.  Young: 
"The  patient  is  given  three  glasses  of  water  to  drink,  and  is  then 
catheterized  and  the  bladder  washed  out  just  before  inserting  1  c.c. 
of  fluid  containing  (i  mg.  of  the  drug  intramuscularly  or  intravenously. 
The  time  of  the  appearance  of  the  first  faint  pinkish  tinge  as  the  urine 
escapes  from  the  catheter  into  the  test-tube,  made  alkaline  by  adding 
a  drop  of  25  per  cent.  XaOH  solution,  is  noted  as  the  beginning  of  the 
61 


962  SURGERY  OF   THE  BLADDER  AXD   KIDNEYS 

test."  In  healthy  patients  the  drug  appears  in  the  urine  about  seven 
minutes  after  it  is  administered;  40  to  60  per  cent,  is  excreted  in  the 
first  hour,  and  from  20  to  25  per  cent,  in  the  second  hour.  The  phlo- 
ridzin  test  is  less  accurate:  this  is  based  on  the  power  of  the  normal 
kidney  to  excrete  sugar  within  a  given  time;  the  diseased  kidney  loses 
in  part  or  entirely  its  permeability  to  sugar.  After  the  ureteral  cath- 
eters are  in  place,  20  minims  of  a  1  per  cent,  solution  of  phloridzin 
are  injected  hypodermically;  glycosuria  should  appear  within  from 
fifteen  to  thirty  minutes,  and  usually  disappears  after  three  hours. 
Cryoscopy,  the  estimation  of  the  freezing-point  of  the  blood  and  urine, 
is  rather  a  complicated  test,  and  of  uncertain  value. 

SURGERY  OF  THE  BLADDER. 

Exstrophy  of  the  Bladder  is  a  congenital  deformity  due  to  a  defect 
in  the  closure  of  the  hypogastric  region  of  the  abdominal  wall.  The 
pubic  bones  often  are  ununited,  and  epispadias  Tp.  1045)  and  sometimes 
inguinal  hernia  may  also  be  present.  The  deformity  is  much  commoner 
in  male  than  in  female  children.  The  anterior  wall  of  the  bladder 
being  absent,  the  intra-abdominal  pressure  forces  out  the  posterior 
wall,  and  the  mucous  surface  presents  itself  as  a  red,  moist  protrusion, 
often  with  the  ureteral  orifices  readily  visible.  Urine  dribbles  con- 
stantly, the  mucous  membrane  and  surrounding  skin  become  much 
inflamed,  and  ascending  infection  of  the  kidneys  almost  invariably 
follows;  it  is  said  that  in  about  half  the  cases  death  ensues  from  this 
complication  before  the  tenth  year. 

The  only  effective  treatment  is  by  operation,  of  which  there  are  two 
main  classes: 

1.  Those  which  aim  to  cover  in  the  protruding  bladder  wall  by  some 
form  of  plastic  operation.  Of  these  methods  the  best  is  that  of  John 
Wood  (1865),  in  which  a  cutaneous  flap  from  below  the  umbilicus 
is  inverted  over  the  bladder,  and  is  covered  by  two  flaps  slid  inward 
from  the  groins,  or  by  one  large  "bridge  flap"  from  the  scrotum 
(Richard).  Though  this  does  not  restore  sphincteric  control,  it 
narrows  the  opening  for  the  discharge  of  urine  and  makes  it  possible 
for  the  patient  to  be  kept  clean  by  wearing  a  urinal;  but  in  many 
cases  cystitis  occiu-s  and  vesical  calculi  form,  and  ascending  kidney 
infection  causes  death.  ^Moreover,  if  hairs  grow  on  the  inverted  skin 
surface  they  cause  additional  trouble. 

2.  The  other  plan  of  operation,  and  that  which  is  most  in  favor 
at  the  present  day,  consists  in  transplanting  the  ureters  or,  preferably, 
the  base  of  the  bladder  containing  the  ureteral  orifices,  into  the  large 
bowel  (rectum  or  sigmoid),  thus  allowing  the  urine  to  collect  in  the 
rectum  where  it  may  be  retained  by  the  sphincter  several  hours  at  a 
time.  Here  also,  however,  there  is  great  danger  of  ascending  kidney 
infection,  even  when  the  valve-like  insertion  of  the  ureters  in  the 
bladder  wall  remains  intact  in  the  transplanted  segment;  and  the 
primary  mortality  is  even  higher  than  in  the  autoplastic  methods. 


CYST  IT  IS  9«3 

Urachal  Cysts  and  Fistulae.  II'  the  jilliintoic  duct  of  the  cinhryo 
fails  to  close  at  tlic  uiiiMlicus  a  fistula  remains  whidi  may  discliarf^e 
urine  it"  it  is  patent  all  the  way  down  to  the  hiadder,  or  wliicli  if  closed 
at  its  vesical  end  may  discharge  only  nnicoid  lluid.  Sometimes  a 
fistula  of  the  nrachus  will  close  spontaneously  affer  obstruction  to  the 
natural  outflow  of  urine  is  removed,  hut  in  most  cases  excision  of  the 
fistulous  tract  is  retpiired.  If  the  urachus  closes  at  both  ends,  a  cyst 
may  form  in  its  course.  These  urachal  cysts  seldom  jj;ive  rise  to 
reco,u:ni/,al)le  symi)toms,  and  usually  are  found  unexpectedly  at 
oi)eration.     Excision  is  the  proper  treatment. 

Cystitis.  Inflammation  of  the  urinary  hiadder  in  almost  all  cases 
is  caused  hy  hacteria,  which  are  introduced  from  without  or  which 
reach  it  through  the  urine  d(>livered  from  the  kidneys,  llnless  there 
is  ohstruction  to  the  outflow  of  urine  throuj^h  the  urethra  it  is  difficult 
to  infect  the  healthy  bladder  with  germs  of  ordinary  virulence,  and 
hactcrluria  (see  helow)  may  exist  a  long  time  without  the  occurrence 
of  cystitis.  An  ordinary  mild  attack  of  cystitis  tends  to  spontaneous 
recovery;  but  the  occurrence  of  congestion  of  the  hiadder  (from  internal 
medication,  exposure  to  cold,  instrumentation,  etc.)  predisposes  it  to 
infection,  as  does  the  presence  of  foreign  bodies  (calculi).  Unclean, 
or  e\en  clean  catheterization,  if  frequently  repeated,  is  the  most 
frequent  cause  of  cystitis;  but  extension  backward  of  an  acute  or 
chronic  urethritis,  or  the  descent  from  the  kidney  of  urine  contaminated 
with  tubercle  or  typhoid  bacilli,  are  other  usual  causes.  Colon  bacilli 
are  those  most  often  introduced  by  instrumentation. 

The  usual  changes  met  with  in  inflammation  of  mucous  surfaces 
are  present:  an  abundant  mucous  secretion,  desquamation  of  epithe- 
lium, and  if  the  infection  is  severe,  ulceration  of  the  bladder.  Perfora- 
tion is  excessively  rare.  In  cases  of  long  standing,  infiltration  of  the 
bladder  wall  occurs,  the  muscular  coat  is  more  or  less  replaced  by 
fibrous  tissue,  and  as  this  contracts  the  capacity  of  the  hiadder  is 
much  decreased  and  its  elasticity  is  destroyed. 

Symptoms. — Pain,  frequency  of  urination,  and  changes  in  the  com- 
position of  the  urine,  are  the  cardinal  symptoms  of  cystitis.  The 
pain,  which  is  felt  mostly  in  the  perineum  or  behind  the  pubis,  varies 
with  the  acuteness  of  the  attack,  and  may  be  present  only  during 
urination,  or  there  riiay  be  a  constant  burning  or  sense  of  weight. 
The  urine  is  passed  frequently,  in  small  quantities,  and  with  consider- 
able tenesmus;  it  is  clouded  l)y  pus  and  mucus,  and  occasionally  is 
blood-stained.  The  pus  will  cloud  all  the  urine,  wdiether  this  is  collected 
in  one,  two,  or  more  glasses.  In  acid  urines  are  found  the  B.  coli 
conmumis,  B.  tuberculosis,  B.  typhosus,  pneumococcus,  and  gono- 
cocc-us;  in  alkaline  urines,  staphylococci,  streptococci,  B.  proteus,  etc. 
Constitutional  symptoms  are  unusual  except  in  very  severe  grades 
of  acute  cystitis,  and  they  often  indicate  renal  complications. 

Treatment. — ^As  already  noted,  most  eases  of  cystitis  tend  to  spon- 
taneous recovery  unless  there  is  urethral  obstruction,  or  unless  the 
infecting  source  continues  active.    The  first  point  in  treatment  is  to 


9G4  SURGERY  OF   THE  BLADDER  AXD  KIDXEYS 

determine  the  source  of  infection  and  remove  it.  If  na  exterior  source 
can  be  determined,  and  if  no  urinary  obstruction  exists,  it  is  probable 
that  the  kidney  is  at  fault.  If  cystoscopy  cannot  be  done  the  fact 
that  the  cystitis  has  its  origin  in  an  infected  kidney  often  must  be 
surmised  only  by  exclusion  of  all  other  factors,  and  by  noting  pain 
and  tenderness  over,  and  perhaps  enlargement  of  the  kidney. 

In  the  Acute  Stages. — Put  the  patient  to  bed  and  keep  him  on  a 
liquid  diet,  with  plenty  of  water,  and  some  demulcent  such  as  flaxseed 
tea.  x\n  alkaline  diuretic  should  be  given,  especially  citrate  or  acetate 
of  potash;  and  when  the  most  acute  symptoms  subside,  some  anti- 
septic such  as  phenyl  salicylate  or  hexamethylenamine  may  be  admin- 
istered. Watson  says  the  urine  should  be  made  alkaline  before  these 
are  employed,  to  avoid  too  great  irritation  of  the  bladder;  others 
think  hexamethylenamine  is  valueless  so  long  as  the  urine  is  alkaline. 
If  there  is  much  pain  or  violent  tenesmus,  no  hesitation  should  be 
felt  in  giving  opium  and  belladonna  by  rectal  suppositories  or  hypo- 
dermically.  Local  hot  applications  (sitz-baths)  are  grateful  to  the 
patient;  and  in  case  retention  of  urine  (p.  lOloj  occurs,  every  such 
method  should  be  tried  before  resorting  to  catheterization,  and  if  this 
becomes  necessary'  only  a  soft  instrument  should  be  used. 

When  the  chronic  stage  is  reached  much  good  may  be  accom- 
plished by  irrigation  of  the  bladder.  Saline  or  boric  acid  solution 
may  be  used  in  ordinary  cases,  and  in  more  rebellious  cases  per- 
manganate of  potash  (1  to  8000)  or  silver  nitrate  solutions  (I  to 
2000  to  1  to  100).  Irrigation  of  the  Bladder  is  best  accomplished 
through  a  soft  catheter,  to  the  outer  end  of  which  a  small  funnel  is 
attached;  the  fluid  is  then  allowed  to  run  in  gently  by  the  force  of 
gravity.  By  inserting  a  nozzle  just  within  the  meatus,  and  raising 
the  reservoir  to  a  height  of  from  three  to  five  feet,  it  is  possible  to 
overcome  the  sphincter  and  irrigate  the  bladder  without  the  intro- 
duction of  a  catheter;  but  unless  very  skilfully  done  this  method  is 
more  painful.  Not  more  than  a  couple  of  ounces  should  be  introduced 
at  first,  but  after  several  sittings  which  should  take  place  every  second 
or  third  day,  the  amount  may  be  increased  up  to  the  tolerance  of  the 
bladder.  The  surgeon  should  not  imagine,  however,  that  he  is  opera- 
ting by  a  species  of  hydraulic  mining,  and  no  force  whatever  must 
be  employed.  In  chronic  cystitis  with  urinary  obstruction  it  often  is 
well  to  let  the  catheter  remain  in  place,  thus  securing  better  drainage; 
and  as  a  last  resort  it  may  be  necessary  to  perform  suprapubic  or 
perineal  cystotomy  to  secure  free  drainage. 

Bacteriuria. — Bacteriuria  is  a  condition  in  which  bacteria  are  found 
in  large  quantities  in  the  urine,  but  in  which  local  symptoms  are 
slight  or  absent.  The  bacteria  most  often  encountered  are  the  colon 
and  typhoid  bacillus  and  the  Staphylococcus  albus.  The  source  which 
supplies  the  bacteria  (kidney,  prostatic  urethra)  should  be  deter- 
mined and  suitably  treated.  Bladder  irrigations  are  of  no  use;  but 
deep  injections  into  the  prostatic  urethra,  or  irrigation  of  the  kidney 
pelvis  after   catheterization  of    the  ureter,   usually  prove   efficient. 


TUBERCrLOSIS   OF    THE   /if.ADDEh'  905 

Wlion  no  source  of  infection  can  be  detected,  a  prolonged  course  of 
urinary  antiseptics,  or  administration  of  autogenous  vaccines  may 
pro\c  curative. 

Diverticula.  I)i\erticula  of  the  bladder  sometimes  occur  in  cases 
of  chronic  cystitis,  usually  as  the  result  of  back  pressure  from  urethral 
obstruction.  They  are  most  frequent  on  the  extraperitoneal  surface 
of  the  bladder.  'J'he  urine  which  X'oUects  in  them  stagnates,  and 
calculi  fre(|ucntly  form.  Occasionally  perforation  occurs.  The  diag- 
nosis is  best  made  by  cystoscopy;  but  occasionally  the  presence  of 
a  diverticulum  may  be  suspected  if  residual  urine  is  found  sometimes 
but  is  entirely  absent  at  other  times,  or  if  after  washing  out  the 
bladder  until  the  solution  returns  clear,  a  sudden  gush  of  purulent 
urine  occurs. 

Treatment. — The  only  satisfactory  treatment  is  excision  of  the  diver- 
ticulum; at  the  same  time,  or  previously,  all  causes  of  urinary  obstruc- 
tion should  be  overcome.  If  operation  is  refused,  temporary  improve- 
ment may  be  secured  by  vesical  irrigation  and  treatment  of  the  urinary 
obstruction. 

Tuberculosis. — Tuberculosis  of  the  bladder  almost  always  is  sec- 
ondary to  the  disease  elsewhere  in  the  body,  especially  in  the  kidney 
or  epididymis.  Although  constantly  exposed  to  infection  when  the 
secretions  of  these  organs  enter  it,  the  bladder  successfully  resists 
infection  for  a  long  time,  and  even  when  infected  is  able  for  a  long 
time  to  recover  its  health  spontaneously  if  the  source  of  infection  is 
removed.  If  this  source  is  the  kidney,  the  vesical  lesion  begins  around 
the  ureteral  orifice;  while  if  infection  is  received  from  the  ejaculatory 
ducts  tlu-ough  the  urethra,  the  vesical  trigone  is  the  part  first  affected. 
The  affected  areas  are  at  first  mere  patches  of  congestion ;  then  whitish 
tuberculous  nodules  appear,  break  down,  and  form  small  round  ulcers 
which  tend  to  preserve  this  typical  rounded  form  even  when  they 
have  coalesced.  Advent  of  mixed  infection  causes  rapid  spread  of 
the  lesions 

Symptoms. — Frequency  of  urination  is  the  earliest,  and  for  a  long 
time  may  be  the  only  subjective  symptom,  though  blood  in  micro- 
scopic quantities  usually  will  be  found  in  the  urine  if  looked  for.  As 
the  process  advances,  urination  becomes  excessively  painful,  there  is 
great  and  incessant  tenesmus,  and  the  pain  is  referred  to  the  end  of 
the  penis,  the  thighs,  and  the  perineum.  The  urine  is  acid,  increased 
in  quantity,  and  in  time  becomes  intermittently  or  constantly  bloody 
and  shreddy.  By  this  time  signs  of  tuberculosis  elsewhere  in  the 
body  usually  have  appeared.  The  finding  of  tubercle  bacilli  in  the 
urine  may  be  very  difficult,  but  innoculation  experiments  may  serve 
to  confirm  the  diagnosis. 

Treatment. — In  addition  to  the  general  treatment  suitable  in  every 
case  of  tuberculosis,  it  usually  is  possible  to  cause  arrest  or  even 
complete  cure  of  the  vesical  lesion,  if  the  primary  focus  (kidney, 
testicle,  etc.)  is  removed.  Even  if  both  kidneys  are  diseased,  it  seems 
that  the  removal  of  the  more  diseased  organ  improves  the  condition, 


966  SURGERY  OF   THE  BLADDER  AND   KIDNEYS 

not  only  of  tlic  Ijladdcr,  but  of  tlu'  reiiiaiiiiiig  kidney.  In  cases  in 
which  the  disease  seems  i)riniary  in  the  bladder,  local  treatment  may 
be  relied  on.  Bransford  Lewis  recommends  injecticjns  into  the  bladder 
of  iodoform  emulsion,  or  distention  of  the  bladder  by  air.  As  a  last 
resort  suprapubic  drainage  may  be  adopted  to  promote  euthanasia. 

Tumors  of  the  Bladder,  except  papilloma  and  carcinoma,  are  rare. 
In  children  sarcoma  sometimes  is  seen.  Pathologically,  papilloma 
is  a  benign  neoplasm,  but  clinically  it  reseml)les  malignant  tumors 
in  its  tendency  to  recurrence,  and  according  to  some  authorities  it 
frequently  undergoes  carcinomatous  transformation.  So  long  as  it 
is  benign  clinically  it  forms  a  more  or  less  j)edunculated  villous 
tumor,  with  a  })ase  which  moves  freely  on  the  muscular  wall  of  the 
bladder.  Carcinoma  is  hard,  nodular,  infiltrating,  and  becomes  fixed 
to  surrounding  structures,  such  as  prostate  or  vagina. 

Symptoms. — The  earliest  symptom  of  a  vesical  tumor  is  hematuria, 
which  is  usually  painless  at  first,  and  characterized  by  the  irregularity 
of  its  occurrence.  It  may  be  profuse,  and  eventually  causes  grave 
secondary  anemia.  Malignant  tumors  may  be  excessively  painful,  so 
that  examination  without  a  general  anesthetic  may  pro\'e  impossible. 
The  usual  occurrence  of  cystitis  adds  its  symptoms  to  those  due  to 
the  vesical  tumor  itself.  The  diagnosis  is  best  made  by  cystoscopy, 
taking  means  to  secure  a  clear  medium  by  the  local  use  of  adrenalin 
to  check  bleeding  or  by  constant  irrigation.  If  this  is  impossible, 
suprapubic  cystotomy,  which  often  is  required  for  treatment,  may  be 
used  for  diagnosis. 

Treatment. — Small  and  well  pedunculated  papillomas  may  be  re- 
moved by  the  operating  cystoscope  by  snaring  and  cauterization  of 
their  bases.  Larger  or  recurrent  growths  require  suprapubic  cystotomy, 
with  wide  excision  of  mucosa  with  the  pedicle,  the  wound  being 
cauterized  and  the  bladder  drained.  ]\Ialignant  growths  require  ex- 
cision of  the  entire  thickness  of  the  bladder  wall.  Sometimes  this 
involves  extirpation  of  the  bladder,  with  transj^lantation  of  the 
ureters  into  the  rectum  or  the  skin  of  the  loin;  or  bilateral  nephros- 
tomy may  be  done.  The  mortality  is  about  30  per  cent.,  and  about 
half  the  patients  have  recurrence  within  a  year.  P'ulguration  is  effi- 
cient in  many  benign  tumors,  and  may  be  repeated  in  case  of  recur- 
rence, and  often  is  useful  as  a  palliative  measure  in  otherwise 
inoperable  conditions. 

Vesical  Calculus. — The  pathogenesis  of  urinary  calculi  is  discussed 
in  connection  with  kidney  stones  (p.  977).  The  majority  of  vesical 
calculi  have  descended  from  the  kidneys  where  they  were  originally 
formed.  Such  stones  are  composed  of  uric  acid,  having  been  formed 
in  acid  (uninfected)  urine.  But  while  lying  in  the  bladder  they  may 
subsequently  become  encrusted  with  triple  phosphates,  if  the  urine  is 
alkaline  and  cystitis  is  present.  Pure  phosphatic  calculi  may  also  be 
formed  in  the  bladder,  under  the  conditions  just  mentioned.  Calculi 
of  amorphous  phosphates,  however,  are  formed  in  urine  which  is  alka- 
line or  neutral  when  it  leaves  the  kidney,  and  are  not  caused  by  ^'esical 


VESICAL  CALCULUS  967 

iiileclioii  ami  alkaline  (locoinpo^sition  ot"  iiriiii'  in  I  he  Madder  us  are 
those  composed  of  triple  phosphates,  (calculi  of  oxalate  of  lime  (called 
niulhcrrt/  calculi  from  their  ai)pearance)  are  next  most  frequent  to 
calc-uli  composed  of  nric  acid  and  triple  j)liosphates,  which  together 
form  90  per  cent,  of  all  urinary  calculi,  more  than  hall"  of  all  calculi 
being  uric  acid. 

Vesical  calculus  is  more  frequent  in  men,  and  in  children,  than  in 
women.  In  women  aufl  children  phosphatic  calculi  are  very  rare. 
( "alcnli  \  ary  in  si/.e  from  those  just  too  large  to  he  passed  sj)ontaneously 
to  those  which  fill  the  bladder.  Calculi  small  enough  to  he  passed 
through  the  urethra  (usually  less  than  1  gram  in  weight)  are  classed 
as  gravel.  A  calculus  weighing  more  than  a  few  ounces  is  rare. 
I'sually  only  one  calculus  is  present,  and  very  .seldom  are  there  more 
than  five  or  six. 

The  chief  predisyosing  causes  for  the  formation  of  calculi  in  the 
bladder  are  urinary  obstruction  and  vesical  infection.  Hence  most 
j)hosphatic  calculi  are  met  with  in  cases  of  stricture  of  the  urethra 
and  enlargement  of  the  prostate.  Foreign  bo(Hes  in  the  bladder 
(broken  ends  of  catheters,  etc.)  usually  become  encrusted  with  phos- 
phates owing  to  the  development  of  cystitis.  If  there  is  no  obstruc- 
tion and  the  urine  remains  acid,  stones  very  rarely  form  in  the  bladder, 
and  those  which  descend  from  the  kidne}-  may  be  passed  by  urethra. 

Symptoms. — Pain  and  hematuria  are  the  chief  symptoms.  The  pain 
is  characterized  by  two  features:  (1)  It  is  made  worse  by  motion, 
exercise,  jolting  in  a  carriage,  etc.;  and  (2)  it  occurs  especially  at  the 
end  of  urination,  when  the  bladder  contracts  on  the  calculus.  The 
pain  is  felt  in  the  neck  of  the  bladder  and  is  referred  mostly  to  the 
glans  penis,  and  sometimes  to  the  perineum,  rectum,  or  thighs.  Per- 
sistent tenesmus  may  produce  prolapse  of  the  rectum  or  hemorrhoids. 
Sometimes  hyperacid  urine,  in  the  absence  of  calculi,  may  cause  similar 
symptoms;  and  sometimes  a  calculus  lodged  in  a  diverticulum  or 
behind  an  enlarged  prostate  may  be  so  fixed  as  to  cause  no  distinctive 
symptoms.  Bleeding  occurs  irregularly,  rarely  being  profuse.  It  is 
increased  by  motion,  and  seldom  appears  except  at  the  end  of  urina- 
tion.    The  blood  is  bright  red,  as  if  recent. 

Diagnosis. — The  diagnosis  of  vesical  calculus  depends  upon  detecting 
tlie  stone  by  a  sound,  by  cystoscopy,  or  by  skiagraphy  (Fig.  907). 
A  vesical  sound,  or  stone  searcher  (Fig.  910)  resembles  an  ordinary 
urethral  sound  except  that  its  shaft  is  smaller  and  longer,  and  its  beak 
shorter  and  more  abruptly  curved.  Before  sounding  about  4  ounces  of 
fluid  should  be  injected  into  the  bladder,  if  this  has  been  recently  emp- 
tied. Fir.st  explore  the  centre  of  the  bladder  and  then  turn  the  beak 
to  each  side  in  turn,  giving  gentle  taps  by  quickly  rotating  the  instru- 
ment between  thumb  and  finger.  Finally  depress  the  shaft  between 
the  patient's  thighs,  reverse  the  beak,  and  explore  the  bas-fond  of  the 
bladder,  particularly  in  cases  of  enlarged  prostate,  by  gently  raising  the 
shaft  again.  The  presence  of  more  than  one  calculus  may  be  ascer- 
tained by  catching  one  in  the  blades  of  a  lithotrite  (Fig.  90S),  and  then 


9G8 


SURGERY  OF   THE  BLADDER   AND  KIDNEYS 


striking  the  other  with  the  instrument.     If  the  calculus  is  lodged  in 
a  diverticulum,  or  covered  by  mucus  or  blood  clot,  it  may  be  impos- 


FiG.  907. — Vesical  calculus  in  a  boy  aged  four  jears.      (Dr.  J.  P.  Hutchinson's 
case.)      Children's  Hospital. 

sible  to  detect  it  by  a  sound;  and  sometimes  phosphatic  incrustations 
on  the  bladder  wall  are  mistaken  for  a  calculus. 


Fig.  908. — Lithotrite  crushing  stone.     (Watson  and  Cunningham.) 

In  most  cases  skiagraphy  is  available,  and  will  demonstrate  the 
number  and  size  of  all  but  the  softest  stones.    Cystoscopy  is  not  often 


VESICAL  CALCULUS 


909 


required,  hut  if  the  surgeon  possesses  a  cystoscopc  and  knows  how  to 
use  it,  no  method  is  so  satisl'iictory. 

Treatment.     'The  stones   must    l)c   rcmoxcih      'rher(>   is   no  solvent 
treatment. 


Fig.  909. — Bigclow's  evacuating  apparatus  withdrawing  fragmeuls  uf  calculus 
from  the  bladder.      (Watson  and  Cunningham.) 

LitJiotrity  and  LitJwIajJaxy. — Unless  the  stones  are  very  hard  (mul- 
berry calculus)  they  may  be  broken  up  into  gravel  inside  the  bladder 
by  means  of  the  lithotrite,  the  operation  being  known  as  lithotrity 
(Civiale,  1824);  the  fragments  are  left  to  be  passed  spontaneously. 
It  is  much  better  to  adopt  Bigelow's  plan  (1878)  or  immediate  evacua- 
tion of  the  fragments  (litholapaxy) .  This  is  accomplished  by  gentle 
kneading  of  the  rubber  bulb  attached  to  the  evacuating  apparatus 
(Fig.  909),  which  procedure  creates  a  swirl  in  the  intravesical  fluid, 
as  a  result  of  which  some  fragments  are  drawn  into  the  bulb  at  each 
motion,  and  by  the  force  of  gravity  fall  into  the  glass  receptacle 
immediately  beneath  the  rubber  bulb.    The  operation  of  litholapaxy  is 


970  SURGERY  OF   THE  BLADDER  AND   KIDNEYS 

not  now  ill  general  use,  because  the  mortality  of  cutting  operations  is 
less  than  it  was  when  Bigelow's  operation  was  introduced,  and  because 
recurrence  of  stone  formation  is  frequent  (IS  per  cent.j,  either  because 
all  the  fragments  are  nrrt  removed  at  first,  or  because  urinary  obstruc- 
tion and  vesical  infection  are  not  relieved.  But  the  primary  mortality 
is  very  low  (under  5  per  cent.),  and  the  operation  may  be  done  under 
local  anesthesia  in  very  debilitated  subjects.  It  is  best  reserved  for 
such  patients,  provided  no  cystitis  is  present. 


Fig.  910. — Instruments  used  in  lithotomy:  1.  Stone  searcher.  2.  Grooved  staff. 
3.  Lithotomy  forceps.  4.  Lithotomy  scoop  (probe  gorget  at  other  end). 

Lithotovty. — Though  in  women  small  calculi  may  be  extracted  by 
dilating  the  urethra  (the  operation  is  termed  lithedasy) ,  in  the  large 
majority  of  cases  of  either  sex,  it  is  best  to  remove  calculi  by  an  incision 
into  the  bladder.  In  patients  under  fifty  years  of  age  the  primary 
mortality  is  low;  it  is  easy  to  ensure  the  removal  of  all  calculi,  efficient 
drainage  is  provided  when  necessary,  and  prostatic  obstruction,  if 
present,  may  be  treated  at  the  same  time.  Several  cutting  operations 
are  available,  but  the  suprapubic  route  is  the  operation  of  choice,  in 
either  sex  and  at  any  age. 

Suprapubic  Cystotomy. — This  may  be  done  under  local  anesthesia, 
but  in  children  a  general  anesthetic  is  preferable.  The  bladder  should 
be  distended  with  from  4  to  6  ounces  of  saline  solution,  and  the  patient 
placed  in  the  Trendelenburg  position.  An  incision  of  2  to  3  inches 
is  made  through  one  or  other  rectus  muscle,  close  to  the  median 
line  and  extending  right  down  to  the  pubis,  opening  the  space  of 
Retzius.  The  fingers  then  draw  upward  the  prevesical  fat  and 
fold  of  peritoneum.  The  bladder  is  recognized  by  its  bluish  color. 
Large  veins  should  be  avoided.  A  traction  suture  is  inserted  in 
the  bladder  wall  on  each  side  of  the  site  of  the  propo.sed  vesical 
incision,  and  the  bladder  is  then  opened  by  the  knife  which  cuts 
downward  toward  the  pubis.  Before  all  fluid  escapes  the  finger  is 
inserted  and  the  cavity  of  the  bladder  explored.  The  stone  is  then 
removed  with  suitable  forceps.  Be  careful  to  remove  all  the  stones 
and  not  to  overlook  one  in  a  diverticulum.  (If  indicated  the  prostate 
may  now  be  removed.  See  p.  1038.)  If  there  is  no  cj'stitis  (which  is 
seldom  the  case)  the  bladder  incision  may  be  closed  completely,  care- 


/AjrA'/A'.s  OF  rinc  in. adder  971 

l'ull\  in\  (Ttiiij^  its  cd^cs  so  as  to  prcxciit  |)rolii])s('  ol"  mucous  ni('nil)raiH\ 
hi  (loiihttul  cases  it  is  hcttcr  to  drain  l)y  iiiscrtin<^  a  tube  as  in  tiic  opera- 
tion of  cliolecystostoniy  (p.  \Y.M)),  carefully  inx-crtin^  the  mucous  mem- 
hraiie.  In  all  cases,  a  small  wick  of  gauze  should  he  placed  in  the  space 
of  Rct/ius.  The  vesical  tube  should  be  allowed  to  come  away  of  itself, 
which  it  usually  docs  in  the  second  week.  The  urinary  fistula  is  then 
encouraged  to  close. 

Perineal  Lithotoviy. — Tiie  lateral  operation,  in  which  the  l)ladder  is 
o])ened  through  the  membranous  and  prostatic  urethra  by  an  incision 
w  hich  i)asses  from  the  base  of  the  scrotum  outward  to  the  left  ischio- 
rectal fossa,  is  seldom  employed  now.  A  grooved  stafi"  (Fig.  01  Oj  in 
the  urethra  is  used  as  a  guide  in  making  tlie  incision.  The  primary 
mortality  is  low,  especially  in  children,  but  the  deep  incision  is  apt  to 
injure  the  ejaculatory  ducts,  only  calculi  of  less  than  2  inches  in 
diameter  can  be  removed,  and  it  requires  considerably  greater  skill 
than  the  suprapubic  operation.  Median  yerineal  Hlhoiomii  has  a  much 
higher  mortality,  and  affords  still  less  room. 

Foreign  Bodies. — Foreign  bodies  in  the  bladder  may  be  removed 
by  experts  with  the  operating  cystoscope.  In  the  hands  of  the  general 
surgeon  more  success  attends  suprapubic  cystotomy;  though  small 
objects  may  be  successfulh'  extracted  by  a  perineal  urethrotomy 
incision  (p.  1022). 

Injuries  of  the  Bladder  are  rare.  Most  frequent  are  ruptures. 
These  may  involve  the  intraperitoneal  or  the  extraperitoneal  surfaces, 
or  both.  They  occur  most  often  in  men,  and  the  chief  predisposing 
cause  is  alcoholic  intoxication:  this  increases  the  quantity  of  urine, 
obtunds  the  sensibilities  so  that  an  overloaded  bladder  is  neglected, 
and  renders  its  subjects  quarrelsome,  helpless,  and  prone  to  injury. 
The  chief  symptoms  are  abdominal  pain  and  bloody  anuria:  the  patient 
desires  to  urinate,  but  only  a  little  blood  is  passed.  Extraperitoneal 
rupture  frequently  complicates  a  fracture  of  the  pelvis,  and  is  difficult 
to  distinguish  from  rupture  of  the  urethra  on  the  pelvic  side  of  the 
triangular  ligament  (see  p.  1017).  In  intraperitoneal  rupture  peri- 
tonitis soon  follows,  as  the  urine  seldom  is  aseptic.  The  diagnosis 
should  be  made  before  this  time  by  means  of  physical  examination. 
A  catheter  should  be  passed  (extreme  asepsis!)  and  any  bloody  urine 
present  should  be  evacuated.  Then  at  least  one  quart  (in  the  adult) 
of  sterile  saline  solution  should  be  injected,  unless  the  development 
of  a  suprapubic  mass  corresponding  to  the  unruptured  bladder  appears 
sooner.  Then  this  fluid  should  be  withdrawn.  Unless  all  the  injected 
fluid  is  regained,  it  is  evident  that  it  has  passed  out  of  the  bladder.  If 
more  fluid  than  was  injected  into  the  previously  emptied  bladder  is 
returned,  it  is  evident  that  fluid  is  being  drained  from  the  peritoneal 
cavity.  In  either  case,  the  abdomen  should  be  opened,  the  rent  in 
the  bladder  sutured  (inverting  its  edges  with  sero-serous  sutures), 
and  the  peritoneal  cavity  drained.  It  is  also  well  to  leave  a  catheter 
in  the  bladder,  draining  it  through  the  urethra.  The  mortality  is 
about  2.3  per  cent.  (Ashhurst,  1906). 


972  SURGERY   OF   THE  BLADDER  AXD   KIDXEYS 

SURGERY    OF    THE    KTONEYS. 

Anomalies  of  Form  and  Position. — One  of  the  commonest  congenital 
malformations  of  the  kidney  is  the  so-called  horseshoe  kidney.  Here 
the  two  organs  are  fused  together,  usually  at  their  lower  poles.  This  is 
found  once  in  about  a  thousand  cases.  It  increases  the  difficulties  of 
diagnosis  and  treatment  of  kidney  lesions.  The  ureters  may  or  may 
not  be  normal  in  such  cases;  but  even  with  normal  kidneys  al)normali- 
ties  of  the  ureters  are  not  very  rare.  The  commonest  abnormality  is 
the  existence  of  two  ureters  to  the  same  kidney;  each  may  spring  from 
a  separate  renal  pelvis,  or  both  may  leave  the  same  pelvis.  The  diag- 
nosis of  such  conditions  sometimes  is  made  before  operation  by  skiag- 
raphy after  catheterization  of  the  ureters  with  instruments  impervious 
to  the  .r-ray  or  after  distending  them  with  collargol.  Anomalies  of  the 
blood-supply  of  the  kidneys  are  frequent.  The  most  important  are 
extra  arteries  to  the  upper  or  lower  pole  of  the  kidney,  or  an  artery 
which  crosses  in  front  of  the  ureter,  and  which  may  be  a  cause  of 
hydronephrosis  by  intermittent  pressure  or  by  causing  kinking  of  the 
ureter.  The  kidney-  may  be  congenitally  misplaced  in  almost  any  posi- 
tion in  the  abdomen,  btit  this  is  very  rare. 

Nephroptosis,  or  Movable  Kidney,  usually  is  regarded  as  an  acquired 
condition,  but  some  investigators  have  found  it  in  a  definite  propor- 
tion of  patients  in  early  infancy.  It  is  more  common  in  women  than 
in  men  (4  to  1),  and  is  predisposed  to  by  anything  which  increases 
the  capacity  of  the  lower  abdomen  (repeated  pregnancies,  removal 
of  pelvic  tumors),  or  which  diminishes  the  room  beneath  the  diaphragm 
(tight  lacing,  scoliosis),  and  which  at  the  same  time  causes  relaxation 
of  the  normal  support  of  the  kidney  (general  poor  health,  or  wasting 
diseases  with  absorption  of  fat).  Nephroptosis  usually  is  present  in 
cases  of  visceroptosis  (p.  S98),  but  frequently  exists  alone.  It  is  more 
common  on  the  right  than  the  left  side,  but  both  kidneys  often  are 
affected. 

Symptoms. — The  patients  usually  are  thin,  long-waisted,  run-down 
women  from  thirty  to  fifty  years  of  age.  In  most  cases  the  condition 
is  unknown  to  the  patient,  and  is  discovered  as  an  incident  in  an 
abdominal  examination.  When  symptoms  exist  the  chief  complaint 
is  weakness  and  dragging  sensations  in  the  loin;  but  no  acute  s\'mptoms 
arise  unless  the  kidney  becomes  twisted  on  its  pedicle,  resulting  in  sud- 
den congestion  from  ^-enou3  stasis  or  blockage  of  the  ureter  with  tem- 
porary hydronephrosis.  Such  acute  attacks  are  known  as  Dietl's  crises 
(18()4).  The  diagnosis  depends  on  recognizing  by  palpation  the  movable 
kidney.  Three  grades  are  recognized:  (1)  When  the  kidney  is  merely 
palpable;  (2)  where  it  is  movable;  and  (3)  where  it  is  floating.  Examina- 
tion is  conducted  with  the  patient  recumbent,  and  the  thighs  flexed 
to  relax  the  abdominal  muscles.  The  stirgeon  places  one  hand  beneath 
the  loin,  and  presses  downward  firmly  but  gently  with  the  other  hand 
in  the  flank,  until  the  two  hands  are  approximated.  Then  when  the 
patient  takes  a  long  breath  the  lower  pole  of  the  kidney,  if  it  is  palpable. 


INFECTIONS  OF    I'lIF   KIDNEYS  5)73 

is  forced  down  against  the  examining  liand.  If  the  kidney  is  trnly 
iiKii'dhlc  it  can  l)e  felt  also  when  the  patient  stands  and  leans  forward, 
resting  her  hands  on  tlie  edge  of  the  hed.  'J'he  examiner  now  stands 
behind  her,  and  works  his  hand  gently  npward  from  the  iliac  fossa 
toward  the  flank;  whereupon,  during  deep  inspiration,  a  movable  mass 
may  be  recognized,  which  slijis  back  to  the  loin,  during  exi)iration. 
A  jUmfiiuj  kidney  can  almost  be  grasped  in  the  fingers,  and  may  be 
found  in  the  iliac  fossa  or  the  pelvis.  Fixation  of  such  a  floating 
kidney  in  abnormal  position,  by  adhesions  or  otherwise,  constitutes 
a  dislocated  kidney.  This  is  a  very  rare  condition.  A  Dietl's  crisis 
is  recognized  by  its  occurrence  in  a  patient  with  a  floating  or  movable 
kidney,  by  the  sudden  increase  in  size  of  the  tumor,  by  the  attending 
constitutional  disturbance  (nausea,  vomiting,  shock,  perhaps  chills 
and  fever),  by  the  absence  of  intestinal  or  peritoneal  symptoms,  and 
by  prompt  subsidence  of  symptoms  when  the  kidney  becomes  un- 
twisted on  lying  down  or  by  manipulation.  Subsequently  microscopical 
study  of  the  urine  may  show  blood. 

Treatment. — If  no  symptoms  exist,  no  treatment  is  indicated  beyond 
building  up  the  patient's  general  health.  If  symptoms  are  present 
they  often  are  relieved  by  a  rest-cure,  with  forced  feeding,  or  by  the 
application  of  an  abdominal  belt  such  as  was  advised  for  cases  of 
pendulous  abdomen.  It  rarely  is  desirable  to  use  a  special  pad  o\ev 
the  kidney.  If  recurrent  attacks  of  torsion  occur,  or  if  palliative 
treatment  fails  to  relieve  chronic  symptoms  which  are  undoubtedly 
due  to  the  mobility  of  the  kidney,  this  organ  may  be  fixed  in  its  proper 
position  by  operation  (nephropexy).  Various  methods  are  employed. 
In  all  it  is  important  to  secure  the  kidney  in  a  position  as  nearly  normal 
as  possible,  avoiding  particularly  excessive  rotation  of  the  organ  in 
any  direction.  One  of  the  most  satisfactory  operations  is  to  incise 
the  capsule  along  the  convexity  of  the  kidney,  to  peel  the  capsule 
back  in  two  leaves,  and  to  suture  these  to  the  lumbar  aponeurosis 
(Edebohls,  1901).  The  lumbar  wound  is  closed  in  layers  without 
drainage.  Another  method  is  to  support  the  kidney  in  the  depths  of 
the  wound  by  two  slings  of  gauze,  one  under  each  pole;  the  gauze  is 
left  in  place  for  a  week  or  ten  days,  and  the  adhesions  which  result  in 
the  extensive  granulating  wound  are  supposed  to  hold  the  kidney  in 
place.  Da  Costa  employs  slings  each  of  which  is  made  by  suturing 
together  with  catgut,  end-on,  two  pieces  of  gauze,  the  sutured  portion 
is  placed  around  the  kidney,  and  when  the  catgut  has  been  absorbed, 
the  ends  of  the  slings  are  easily  removed. 

Infections  of  the  Kidneys  arise  in  most  cases  either  from  the  blood- 
stream or  as  ascending  infections  from  the  bladder  or  genitalia. 

Hematogenous  Infections. — The  kidneys  receive  from  the  body  and 
discharge  through  the  urine  great  quantities  of  toxins,  and  in  many 
cases  large  numbers  of  bacteria  (bacteriuria,  p.  964).  If  the  resistive 
power  of  the  kidneys  is  weakened  (previous  renal  disease,  urinary 
obstruction,  trauma,  etc.)  or  if  the  toxins  or  bacteria  are  of  extra- 
ordinary virulence,  inflammation  of  the  kidneys  (nephritis)  results. 


974  SURGERY  OF   THE  BLADDER  AND  KIDNEYS 

There  are  various  forms  of  nephritis,  which  are  best  classed  as  acute 
and  chronic.    Only  some  of  these  need  concern  us  here. 

Cases  of  toxic  nephritis  due  to  mineral  poisons,  and  those  cases  due 
to  toxemia  (as  in  scarlatina,  diphtheria,  influenza,  etc.)  or  auto- 
intoxication (as  in  chronic  intestinal  stasis,  pregnancy,  etc.),  may  be 
acute  but  frequently  are  chronic  from  the  beginning,  and  usually 
are  cared  for  by  the  physician.  Of  late  years,  however,  it  has  become 
possible  to  relieve  some  of  these  patients  by  operative  means.  Punc- 
ture of  the  kidney  or  incision  of  its  capsule  was  advocated  by  R. 
Harrison  in  1897,  by  Ferguson  and  Edebohls  in  1S99,  and  the  latter 
in  1901  reported  a  number  of  cases  in  which  he  had  practised  decap- 
sulation of  the  kidneys.  By  stripping  the  capsule  from  the  contracted 
and  sclerosed  kidney  its  nutrition  is  improved  by  relief  of  tension  and 
perhaps  by  development  of  collateral  circulation.  There  is  no  doubt 
that  in  many  cases  vast  improvement  occurs :  the  amount  of  the  urine 
increases,  the  edema  and  ascites  vanish,  casts  disappear  from  the 
urine,  and  previously  bed-ridden  patients  are  enabled  to  resume  a 
certain  degree  of  activity.  In  favorable  cases  this  improvement  has 
lasted  several  years,  though  evidences  of  chronic  nephritis  persist. 
In  other  patients,  however,  no  improvement  occurs  or  the  state  is  made 
worse.  The  operation  is  still  on  trial.  The  kidney  is  exposed  as  for 
other  kidney  operations  (p.  985),  it  is  brought  into  the  wound,  and 
its  capsule  is  incised  along  the  convexity;  the  flaps  of  the  capsule  are 
then  stripped  off  the  organ  to  the  hilum  on  each  side,  and  are  excised; 
the  kidney  is  replaced  and  the  wound  closed  without  drainage,  but 
not  too  tightly.  It  is  better  to  postpone  operation  on  the  second 
kidney  for  a  week  or  ten  days.  Brewer  recommends  the  operation 
in  cases  of  severe  acute  nephritis,  following  the  exanthemas,  etc. 

Septic  Nephritis. — What  are  commonly  recognized  as  surgical 
infections  of  the  kidney,  of  hematogenous  origin,  are  cases  of  acute 
nephritis  due  to  septic  embolism.  In  a  large  proportion  of  cases  only 
one  kidney  (usually  the  right)  is  affected,  and  the  lesions  vary  from 
hemorrhagic  infarcts  (which  soon  heal,  leaving  minute  cicatrices) 
to  difl'use  suppuration.  Several  foci  of  suppuration  may  coalesce  and 
form  distinct  abscesses.  Extension  to  the  pelvis  of  the  kidney,  causing 
■pyelitis,  is  frequent;  extension  to  the  fatty  capsule  of  the  kidney  and 
surrounding  structures  (perinephritis)  is  less  usual.  In  cases  where 
pelvis  and  kidney  are  diffusely  involved  {x)yeh-nephritis)  it  may  be 
impossible  to  distinguish  the  pathological  changes  from  those  caused 
by  an  ascending  infection. 

Symptoms. — The  recognition  of  acute  unilateral  hematogenous 
infection  of  the  kidney  is  due  mainly  to  the  work  of  Brewer.  Over 
80  per  cent,  of  the  cases  occur  in  women,  frequently  as  a  sequel  of 
some  known  general  infection  (pneumonia,  tonsillitis,  furunculosis, 
etc.).  The  onset  and  course  of  the  disease  may  be  very  acute,  sub- 
acute, or  comparatively  mild.  The  severe  cases  usually  begin  with  a 
chill,  temperature  of  104°  or  lOS""  F.,  rapid  pulse  and  high  leukocytosis. 
From  the  first  the  symptoms  of  toxemia  are  marked,  and  the  local 


INFECTIONS  OF   THE   KIDNEYS  975 

coiulitioii  iii:i.\-  ])«>  ()\tTl()(»ke(l,  the  disease  resenil)lin^  jjerhaps  iriHiiciiza, 
lobar  piieumoiiia,  or  one  of  tlie  exaiithemas.  Suhsequeiitly  attention 
is  (lireeted  to  the  kidney  region  by  pain  and  discomfort  in  the  abdomen 
or  flank,  and  these  may  be  mistaken  for  signs  of  cholecystitis  or 
aj)i)en<li(itis.  ( "()ni])ensatory  action  of  the  healthy  kidney  may  obscure 
urinary  changes  (red-blood  cells,  albumin,  ])us)  unless  especially  looked 
for.  "The  one  pathognomonic  sign  present  in  all  cases,"  adds  Brewer, 
"  is  a  marked  unilateral  costovertebral  tenderness." 

Trr(ifnirnf.~\n  the  severe  cases,  with  high  temperature  and  pro- 
gressive toxemia,  nephrectomy  should  be  done  without  unreasonable 
delay ;  death  is  the  almost  invariable  result  of  such  delay  or  of  j)alliative 
operations.  In  the  milder  cases,  which  Brewer  describes  as  those 
where  the  temperature  begins  to  fall  within  forty-eight  hours,  decap- 
sulation of  the  kidney  may  be  done,  or  nephrotomy  if  there  is  evidence 
of  much  tension  or  localized  suppuration.  In  the  mildest  type,  where 
the  diagnosis  may  be  uncertain,  medical  treatment  may  be  persisted 
in^  and  any  chronic  pyelonephritis  which  remains  may  be  subjected 
to  appropriate  surgical  treatment  subsequently. 

Ascending  Infections. — Ascending  as  well  as  hematogenous  infection 
is  predisposed  to  by  previous  renal  disease  (especially  renal  calculus) 
or  the  occurrence  of  trauma;  but  even  in  such  circumstances  it  rarely 
occurs  unless  there  is  obstruction  to  the  urinary  outflow\  In  women, 
pressure  from  pelvic  tumors  or  the  gravid  uterus  is  a  cause  of  urinary 
obstruction  which  leads  not  infrequently  to  ascending  kidney  infec- 
tion. In  men  such  obstruction  is  due  in  most  instances  to  enlarge- 
ment of  the  prostate  or  stricture  of  the  urethra.  Back  pressure  of 
urine  within  the  bladder  first  compresses  the  ureteral  orifices,  damming 
the  urine  back  into  the  ureters  and  kidneys;  inflammatory  infiltration 
of  the  bladder  wall  from  cystitis  may  impair  the  sphincteric  action 
of  the  ureteral  orifices;  and  if  extreme  dilatation  of  the  bladder  occurs 
the  ureteral  orifices  may  become  constantly  patulous,  by  the  approxi- 
mation of  their  course  through  the  bladder-walls  to  a  straight  line. 
It  is  probable  also  that  infection  extends  up  the  Avails  of  ureters  to 
the  kidney  pelvis,  and  thus  produces  pyelitis  and  pyelo-nephritis, 
which  are  the  usual  results  of  obstruction  in  the  presence  of  infection. 
In  some  cases  the  ureters  appear  unaffected,  but  in  most  they  are 
dilated,  pouched  and  perhaps  strictured.  The  pyelo-nephritis  arising 
from  ascending  infection  is  commonly  spoken  of  as  surgical  kidney. 
The  renal  cortex  is  thinned,  the  pelvis  enlarged,  and  the  kidney  sub- 
stance is  riddled  with  al)scesses  of  various  sizes. 

Symptoms. — Surgical  kidney  is  more  frequent  in  the  aged  than  in 
the  young,  and  occurs  very  much  oftener  in  men  than  in  women. 
It  may  be  acute  or  chronic,  but  as  acute  attacks  tend  to  be  prolonged 
by  chronic  symptoms,  and  as  the  chronic  condition  frequently  is 
interrupted  by  acute  attacks,  the  symptomatology  is  best  considered 
together.  The  onset  usually  is  acute,  and  often  follows  exposure 
to  cold  or  wet,  the  passage  of  a  catheter,  sounding  for  .stone,  or  dilata- 
tion of  a  urethral  stricture.    The  patient  has  a  chill,  is  nauseated,  his 


*)7()  SURGERY  OF   THE  BLADDER   AND   KIDNEYS 

temperature  rises,  and  for  a  few  hours  he  may  be  very  ill.  In  many 
cases  these  symptoms  cannot  be  distinguished  from  those  of  so-called 
urethral  fever  (p.  102()),  but  the  diagnosis  of  pyelitis  is  probable  if 
fever  continues,  and  becomes  almost  a  certainty  if  there  is  a  dull  ache 
in  one  or  both  loins  and  if  an  enlarged,  tender  kidney  can  be  palpated. 
The  urine  contains  pus,  sometimes  blood,  and  usually  is  alkaline. 
The  pus  settles  slowly  to  the  bottom  of  the  receptacle,  whereas  the 
pus  of  cystitis  settles  very  quickly. 

One  or  both  kidneys  may  be  affected.  If  only  one  is  affected  and 
the  ureter  is  completely  blocked,  the  urine  may  be  fairly  normal,  while 
the  patient's  condition  will  grow  worse;  on  the  other  hand,  if  free 
drainage  of  the  kidney  is  present  the  patient  may  feel  quite  comfortable 
in  spite  of  the  infected  character  of  his  urine.  In  the  average  chronic 
case,  so  long  as  the  kidney  drains  freely,  the  patient  may  be  little 
troubled  by  subjective  symptoms  unless  an  exacerbation  occurs  from 
renewed  irritation  of  the  urinary  passages,  or  indiscretions  in  diet,  etc. 
Recurrence  of  acute  attacks  is  common,  as  the  kidney,  unlike  the 
bladder,  has  no  great  tendency  to  sterilize  itself  spontaneously. 

Treatvieni.— In  the  acute  cases  put  the  patient  to  bed,  and  ensure 
free  drainage  of  urine  from  the  bladder  by  an  inlying  catheter  if  neces- 
sary. Keep  the  patient  on  a  milk  diet,  and  make  him  drink  plenty 
of  water.  Give  15  grains  of  urotropin  three  times  daily.  Treat 
threatening  uremia  by  diuretics,  cathartics,  sweating,  and  if  necessary 
venesection.  If  the  urine  is  nearly  normal,  or  anuria  is  present,  and 
the  kidney  enlarged  and  tender,  nephrotomy  or  rarely  nephrectomy 
may  be  required;  but  whenever  possible  radical  operation  should  be 
postponed  until  the  acute  attack  subsides.  When  the  chronic  stage 
is  reached,  radical  treatment  of  the  obstructing  cause  (stricture, 
enlarged  prostate,  etc.)  may  succeed  in  curing  the  pyelitis.  Before 
nephrectomy  is  done,  in  any  case,  the  functional  capacity  of  the  other 
kidney  must  be  proved  adequate  (p.  961). 

Hydronephrosis. — This  is  hydrops  of  the  kidney  due  to  urinary 
obstruction,  in  the  absence  of  infection.  The  condition  may  be  unilat- 
eral or  bilateral.  Causes  of  unilateral  hydronephrosis  are  recurrent 
torsion  of  the  ureter  by  the  vagaries  of  a  movable  kidney;  impaction 
of  a  stone  in  the  ureter  without  complete  blocking  of  the  canal;  or 
stricture  of  the  ureter.  Bilateral  hydronephrosis  is  due  to  obstruction 
of  both  ureters,  either  directly,  as  by  a  tumor  of  the  bladder  involving 
both  ureteral  orifices,  pressure  of  a  pelvic  tumor,  etc.,  or  indirectly  by  en- 
largement of  the  prostate,  stricture  of  the  urethra,  etc.  The  symptoms 
occur  as  a  sequel  to  those  due  to  the  obstructing  lesion;  the  kidney 
becomes  enlarged  and  may  reach  an  immense  size.  If  temporary 
relief  of  the  obstruction  occurs,  the  accumulated  urine  is  discharged, 
with  polyuria  and  disappearance  of  the  tumor.  This,  however,  may 
soon  refill  {intermittent  hydronephrosis). 

Treatment. — Treatment  comprises  removal  of  the  obstruction  when 
this  is  possible.  A  movable  kidney  may  be  fixed;  a  stone  in  the  ureter 
removed;  a  stricture  of  the  ureter  treated  by  dilatation,  ureteroplasty 


NErnuourn/ASis  977 

(analogous  to  pyloroplasty)  or  hy  resection  arul  eiul-to-erul  suture; 
a  pel\ic  tumor  may  he  excised.  Finally,  if  no  obstruct  ion  can  be 
found,  or  if  it  camiot  he  remo\('d,  and  the  kidney  is  fun<  tionless, 
nephrcctoinx    may  Ix*  done. 

Pyonephrosis.  I'yoneijhrosis  occurs  as  tiie  end-result  of  pyelo- 
ne|)hritis,  or  it  may  he  due  to  the  infection  of  a  j)re("'.\istinf,'  hydro- 
nejjhrosis.  If  the  other  kidney  is  functionally  sufficient,  nephrectomy 
sliouid  he  done.  Nephrotomy  with  drainaji;e  rarely  i.s  beneficial,  and 
in  most  eases  nephrectomy  and  death  are  the  only  alternati\es,  and 
death   may  follow  nephrectomy. 

Perinephric  Abscess. — This  is  suppuration  in  the  fatty  capsule  of 
the  kidney.  1  have  already  mentioned  the  occurrence  of  perineph- 
ritis as  a  sequel,  of  septic  nephritis;  and  though  perinephritis  often 
results  in  sup])uration  there  are  many  other  causes  for  perinephric 
abscess;  hence  the  term  peri  nephritic  abscess  should  not  be  used, 
the  kidney  being  at  fault  only  in  about  one-fifth  of  the  cases  (M.  B. 
Miller,  1909).  In  most  cases  the  source  of  infection  is  in  the  lower 
genito-urinary  tract,  and  extension  to  the  j)erirenal  tissues  occurs 
along  the  lymphatics.  Trauma  may  be  a  predisposing  cause.  Pul- 
monary complications  are  frequent. 

Symptoms. — Symptoms  often  are  subacute  in  onset,  and  the  patient 
may  not  be  laid  up  until  a  week  or  more  has  elapsed.  He  complains 
of  local  pain  and  tenderness,  walks  guardedly,  with  his  body  bent 
toward  the  affected  side;  and  the  thigh  is  slightly  flexed;  there  is  local- 
ized muscular  rigidity,  and  a  tender  spot  between  the  twelfth  rib  and 
iliac  crest  posteriorly.  Later  there  may  be  moderate  or  high  elevation 
of  temperature;  leukocytosis  usually  is  high  (average  is  25,000) ;  and  still 
later  distinct  evidences  of  suppuration  develop.  Sometimes,  however, 
the  onset  is  very  acute,  wdth  chill,  high  fever,  and  extreme  prostration. 
The  diagnosis  is  not  always  easy,  even  if  the  condition  is  kept  in  mind. 
A  source  of  infection  should  be  looked  for.  Confusion  wnth  a  lumbar 
abscess,  due  to  Pott's  disease  of  the  spine,  should  not  arise  unless  such 
a  cold  abscess  is  secondarily  infected  and  signs  of  spinal  involvement 
are  absent. 

Treatment. — Treatment  consists  in  evacuating  the  abscess  by  a 
lumbar  incision;  and  this  should  not  be  ])ostponed  if  the  symptoms 
are  acute,  even  if  the  diagnosis  is  uncertain. 

Nephrolithiasis  or  Renal  Calculus. — The  urine  of  many  persons 
may  contain  crystalloids  in  abnormal  amount,  yet  so  long  as  they  are 
held  in  solution  by  the  action  of  colloids,  no  stone  will  be  formed. 
If,  however,  the  crystalloids  are  present  in  excess  of  the  power  of  the 
colloids  to  hold  them  in  solution  by  means  of  what  is  known  as  adsorp- 
tion, then  the  crystalloids  (uric  acid,  acid  urates,  calcium  oxalate,  etc.) 
go  out  of  solution  and  are  deposited  on  the  colloids  as  a  matrix.  If 
the  colloids  are  what  are  known  as  reversible  colloids,  such  as  mucin, 
both  they  and  the  mineral  deposited  on  them  may  be  redissolved  by 
more  water.  If,  however,  the  colloid  is  irreversible,  such  as  fibrin, 
it  cannot  be  re-dissolved.  The  colloid  mostly  concerned  in  the  forma- 
62 


978  SURGERY  OF   THE  BLADDER  AND  KIDNEYS 

tion  of  urinary  calculi  is  believed  to  be  fibrin;  and  as  this  is  a  product 
of  inflammation  and  infection,  it  is  not  unreasonable  to  suppose  that 
calculi  may  form  as  the  remote  result  of  an  attenuated  infection  of 
the  urinary  tract,  much  as  gall-stones  are  formed  in  the  biliary  tract. 
But  the  influence  of  infection  in  these  cases  has  not  been  proved, 
and  it  is  customary  to  regard  such  calculi  (uric  acid,  oxalate  of  lime; 
rarely  cystin,  etc.)  as  inimary  calculi,  in  contradistinction  to  those 
undoubtedly  the  result  of  bacterial  infection  of  the  urinary  tract, 
which  are  termed  secondary  calculi.  These  latter  usually  are  composed 
of  triple  phosphates  and  result  from  bacterial  decomposition  of  the 
urine.  Phosphatic  deposits  may  occur  as  laminations  on  primary 
calculi,  as  concretions  on  the  mucous  membrane  lining  the  urinary 
tract,  or  as  distinct  calculi. 

Renal  calculus  is  most  common  between  twenty  and  forty  years  of 
age,  aflfects  men  somewhat  oftener  than  women,  and  the  right  kidney 
a  little  oftener  than  the  left.  Both  kidneys  are  involved  in  from 
20  to  50  per  cent,  of  cases.  The  prevention  of  calculus  formation 
concerns  the  physicians;  when  stones  have  formed  in  the  kidney  the 
case  becomes  surgical. 

The  classification  of  urinary  concretions  as  sand,  gravel,  and  calculi, 
has  already  been  mentioned  (p.  967).  Sand  may  be  productive  of  no 
definite  symptoms;  gravel  gives  rise  to  repeated  attacks  of  renal  colic 
as  the  small  stones  pass  into  or  through  the  ureter;  while  a  calculus 
so  large  as  to  be  relatively  immovable  may  be  symptomless.  The 
smaller  the  calculi,  as  a  general  rule,  the  greater  is  their  number  and 
the  more  apt  are  they  to  produce  symptoms. 

Symptoms. — These  may  be  divided  into  those  of  simple  nephro- 
lithiasis and  those  of  complications  of  the  disease,  such  as  renal  colic, 
hydronephrosis,  pyelitis,  and  its  sequels. 

In  simple  nephrolithiasis  (which  corresponds  to  simple  cholelithiasis) 
the  stones  remain  in  the  kidney  and  infection  is  absent.  There  may 
be  no  symptoms  to  call  attention  to  the  kidney.  What  symptoms  the 
patient  complains  of  usually  are  referred  to  the  bladder,  and  are  the 
effect  of  passage  of  urine  altered  in  quality  or  quantity.  Especially 
valuable  as  suggestive  of  renal  disorder  is  the  occurrence  of  blood  in  the 
urine,  usually  in  microscopic  amount.  It  may  be  present  only  after 
the  patient  has  been  up  and  about,  and  may  disappear  if  he  lies  quiet 
in  bed.  Unless  secondary  infection  occurs,  or  unless  the  kidney  is 
unduly  movable,  and  therefore  liable  to  congestion  or  to  hydro- 
nephrosis, it  is  unusual  for  much  pain  to  be  felt  in  the  kidney  region 
itself  or  for  macroscopical  hematuria  or  pyuria  to  occur.  But  sometimes 
complaint  is  made  of  a  dull  ache  in  the  lumbar  region,  and  quite 
frequently  there  is  tenderness  on  pressure  here,  or  over  the  lower  pole 
of  the  kidney  in  the  flank.  Sometimes  the  kidney  is  palpably  enlarged. 
Murphy  places  special  reliance  on  fist  percussion  over  the  lower  ribs, 
using  one  hand  as  plessimeter  and  thumping  it  with  the  other  fist 
as  plessor.  He  claims  that  in  the  presence  of  a  renal  calculus  this 
always  produces  severe  pain.     Subjective  symptoms,  such  as  pain 


NEPIIROLITIIIASIS  979 

over  the  kidney,  frequently  disappear  as  soon  as  the  patient  goes 
to  bed;  and  after  his  athnission  to  a  hospital  ward  tlie  diagnosis  may 
seem  doubtful.  The  a:-ray  is  of  inestimable  value  in  the  diagnosis  of 
renal  calculus,  but  unfortunately  it  may  be  difficult,  or  impossible,  to 
secure  a  skiagraj)h  which  will  show  calculi  of  pure  uric  acid  (Fig.  911). 
Fortunately  few  calculi  are  composed  of  uric  acid  or  urates  without 
some  admixtures  of  other  salts.  No  plate  should  be  considered  satis- 
factory unless  the  shadow  of  the  psoas  muscle  is  clearly  visible.  Con- 
fusion arises  from  defects  in  the  plate,  shadows  of  fecal  concretions, 
and,  in  the  case  of  ureteral  stone,  from  those  of  phleboliths,  calcifica- 
tion around  ligatures  left  at  previous  pelvic  operations,  etc.  The 
functional  capacity  of  the  other  kidney  (p.  9G1)  should  be  ascertained 
in  everv  case  of  renal  calculus. 


Fig.  911. — Shadows  cast  in  a  radiogram  l)y  different  renal  calculi:  on  the  left,  phosphatic; 
in  the  centre,  uric  acid;  on  the  right,  oxalate  of  lime.     (Rothschild.) 

,  Renal  colic  is  the  most  frequent  symptom  of  complicated  cases  of 
nephrolithiasis,  but  it  may  be  caused  by  other  factors  than  the  passage 
of  a  calculus  through  the  ureter.  The  symptoms  are  the  same  as  in 
cases  of  Dietls's  crisis  (p.  972),  but  in  the  latter  condition  the  kidney 
always  is  movable,  which  is  not  often  the  case  in  nephrolithiasis.  Pain 
is  referred  along  the  course  of  the  ureter,  into  the  testicle,  and  down 
the  thigh,  and  sometimes  to  the  end  of  the  penis.  The  pain  usually 
begins  and  ends  suddenly;  but  if  the  stone  is  impacted  in  the  ureter 
the  pain  ceases  gradually  and  light  attacks  of  colic  recur  often.  There 
may  be  nausea  and  vomiting,  but  there  seldom  is  much  constitutional 
disturbance,  unless  the  kidney  is  infected,  wdien  the  symptoms  of 
pyelitis,  etc.,  arise.  These  have  already  been  considered.  During 
the  continuance  of  the  colic  the  urine  may  be  diminished  or  entirely 
suppressed;  crebruria,  with  tenesmus,  is  frequent,  and  blood  usually 
is  found  in  the  urine. 

Diagnosis  of  Nephrolithiasis. — This  is  not  certain  unless  the  stones 
are  seen  in  a  skiagraph  (Fig.  912);  and  even  then,  as  noted  above, 
sources  of  error  are  not  infrequent.  If  gravel  has  been  passed,  and 
colic  persists,  it  is  a  fair  inference  that  other  stones  remain;  and  the 
diagnosis  is  very  probable  if  repeated  colic  occurs,  with  hematuria 


980  SURGERY  OF   THE  BLADDER  AND  KIDNEYS 

and  occasionally  pyuria,  with  symptoms  of  pyelitis.  The  chief  con- 
ditions from  which  renal  calculus  must  be  distinguished  are  biliary 
colic,  appendicitis,  and  intestinal  obstruction.  The  diagnosis  of  these 
has  alread\'  been  considered. 


Fig.  912. — Skiu^iraph  of  ralculus  in  kidney.     The  faint  sliadow  of  the  psoas 
muscle  is  barely  visible.     Episcoi)al  Hospital. 

Treatment. — If  the  stones  are  shown  b>'  skiagraphy  to  be  merely 
gravel,  and  if  such  haxe  already  been  passed  successfully,  it  is  sometimes 
advisable  to  trust  to  medical  treatment  to  prevent  the  formation  of 
other  calculi,  and  to  allow  the  patient  to  pass  such  as  already  exist 
per  vias  naturales  (Fig.  913).  Any  stone  too  large  to  be  passed 
requires  removal  by  operation ;  especially  is  this  true  when  pyelitis  is 
present  and  fails  to  clear  up  under  palliative  treatment. 

If  the  stones  lie  loose  in  the  kidney  pelvis,  a  fact  which  cannot  be 
determined  before  the  kidney  is  exposed,  they  should  be  removed  by 
pyeloiomy;    if  they  are  fixed  in  the  cortex,  neyhrotomy  (nephrolith- 


CALCULUS  ANURIA  981 

otoiiiy)  should  he  iUnw.  Those  operations  are  deserihed  at  p.  9(S().  If 
the  presenee  of  ealeiih  is  uiu'ertaiii  it  is  better  to  incise  tlie  kiihiey 
sufficiently  to  explore  its  interior  than  to  endeavor  to  locate  the  stone 
by  "needlin<,^"  the  kidney.  In  all  cases  a  sound  or  ureteral  catheter 
should  be  passed  down  the  ureter  to  the  bladder,  to  make  certain 
that    no   ol)stru('ti()n    has   been   overlooked. 


Vn;.  91.S. — Rciiiil  calculus  of  uric  acid  passed  by  urethra.      (Scale  in  inches.) 
Orthopii'dic  Hos|jifal. 

Ureteral  Calculus. — The  .r-ray  has  shown  that  calculus  is  more 
frequent  in  the  ureter  tfian  in  the  kidney  (C.  L.  Leonard).  In  nearly 
afl  cases  the  stone  has  descended  from  tlie  kidney.  It  lodges  by  pref- 
erence (1)  Just  below  the  renal  pelvis;  (2)  at  the  brim  of  the  true  pelvis; 
or  (3)  just  outside  the  bladder  walk  Blockage  of  the  ureter  in  the 
first  position  causes  symptoms  similar  to  those  of  renal  calculus;  in 
the  last  position,  those  resembling  cystitis.  Stones  arrested  at  the 
brim  of  the  pelvis  frequently  are  mistaken  for  chronic  appendicitis, 
and  the  appendix  is  removed  in  vain. 

Complete  blockage  of  the  ureter  may  bring  on  calculous  anuria. 
This  may  be  due  to  the  functionally  useless  state  of  the  second  kidne\'; 
to  blockage  of  both  ureters  at  once;  to  the  existence  of  only  one  kidney, 
or  of  a  horseshoe  kidney  with  a  single  ureter;  or  to  what  is  called 
"reflex  inhibition"  of  the  healthy  kidney.  Unless  relieved  by  opera- 
tion, calculous  anuria  usually  terminates  in  uremia  and  death;  occa- 
sionally death  occurs  suddenly  without  uremic  symptoms.  The  free 
interval  varies  from  one  to  sixteen  days,  but  rarely  is  it  longer  than 
three  or  four  days. 

Treatment. — A  stone  in  the  upper  part  of  the  ureter  often  can  be 
worked  backward  into  the  kidney  pelvis;  if  not,  it  must  be  exposed 
by  enlarging  the  lumbar  wound,  and  removed  by  direct  incision  of  the 
ureter  {ureterolithotomy).  If  in  the  middle  portion  of  the  ureter, 
the  stone  is  best  exposed  extraperitoneally  through  a  McBurney  or 
similar  incision.  As  the  peritoneum  is  stripped  up  from  the  iliac  fossa, 
it  carries  the  ureter  with  it.  Gibbon  places  a  finger  inside  the  peri- 
toneal cavity  to  aid  in  bringing  the  ureter  into  the  wound.  A  stone 
very  near  the  bladder  may  be  reached  extraperitoneally  by  the 
suprapubic  route  (C.  L.  Gibson) ;  vaginal  and  perineal  operations  are 
less  satisfactory.  A  calculus  in  the  intramural  part  of  the  ureter  may 
be  extracted  by  suprapubic  cystotomy,  or  even  by  means  of  the 
operating  cystoscope. 

Calculus  anuria  requires  active  treatment  to  prevent  uremia;  hot 
baths,  sweating  (pilocarpin) ;  morphin  and  atropin  to  allay  pain  and 


982  SURGERY  OF   THE  BLADDER  AND  KIDNEYS 

spasm.  Unless  the  anuria  is  relieved  within  thirty-six  or  at  the  most 
forty-eight  hours,  operation  should  be  done.  There  is  no  time  to 
undertake  an  elaborate  search  for  the  site  of  obstruction  in  the  ureter; 
so  unless  this  is  known  (when  ureterolithotomy  by  the  proper  route 
is  indicated)  the  diseased  kidney  should  be  exposed  and  drained,  the 
radical  operation  being  postponed  until  convalescence. 

Tuberculosis  of  the  Kidney. — Tuberculosis  of  the  genito-urinary 
tract  usually  develops  first  in  the  kidney  (66  per  cent,  of  cases),  or  the 
epididymis  (30  per  cent.) ;  in  a  few  cases  it  appears  first  in  the  Fallopian 
tubes,  the  prostate,  testis,  uterus  or  seminal  vesicles  (Watson  and 
Cunningham).  In  nearly  all  cases  the  infection  is  blood-borne  and 
is  secondary  to  a  focus  elsewhere  in  the  body  (bronchial  or  mesenteric 
lymph  nodes).  The  bladder,  as  pointed  out  at  p.  965,  scarcely  ever 
is  the  first  portion  of  the  genito-urinary  tract  to  be  invaded,  and  as  a 
consequence  ascending  tuberculous  infection  of  the  kidney  is  exceed- 
ingly rare.  Secondary  pyogenic  infection,  however,  frequently  ascends 
from  the  bladder  and  causes  rapid  disintegration  of  the  tuberculous 
kidney. 

In  most  cases  only  one  kidney  (the  right  and  left  about  equally) 
is  affected  at  first,  and  the  other  kidney  may  remain  intact  for  a  long 
time.  The  lesions  commence  in  the  cortex,  but  the  pelvis  is  invaded 
when  rupture  of  the  caseous  foci  occurs.  The  ureter  may  remain 
healthy  long  after  the  infection  has  secured  a  foothold  in  the  bladder. 

The  disease  is  most  frequent  in  early  adult  life,  and  the  sexes  are 
about  equally  affected.  At  the  time  patients  come  to  operation  the 
disease  is  still  confined  to  one  kidney  in  more  than  half  the  cases, 
and  even  at  autopsy  the  second  kidney  is  free  in  about  one  out  of 
three  cases.  In  the  large  majority  of  cases  of  bilateral  disease  the 
second  kidney  is  only  very  slightly  involved. 

Symptoms. — There  are  both  constitutional  symptoms  characteristic  of 
a  tuberculous  lesion,  and  local  symptoms  referable  to  the  urinary  tract. 
Among  the  former  may  be  mentioned  afternoon  pyrexia,  nervousness, 
sleeplessness,  anorexia,  and  loss  of  weight.  Though  the  patient  seems 
ill,  no  definite  cause  is  apparent.  After  weeks  or  months,  urinary 
symptoms  appear.  At  first  these  are  referred  to  the  bladder; 
the  urine  is  passed  frequently;  its  quantity  ,is  increased,  and  its 
specific  gravity  lessened ;  it  contains  pus  and  microscopical  amounts  of 
blood.  Frank  hematuria  is  rare.  Vesical  irritability  may  be  extreme 
before  the  tuberculous  lesion  has  spread  to  the  bladder.  Secondary 
pyogenic  infection  of  the  kidney  causes  hectic  fever,  night  sweats, 
emaciation,  and  rapid  loss  of  strength.  Not  until  this  stage  is  reached 
is  the  acidity  of  the  urine  lost. 

Diagnosis. — Vesical  symptoms  should  not  divert  attention  from  the 
kidney.  Pus  in  the  urine  does  not  necessarily  mean  cystitis.  In  cys- 
titis the  urine  almost  always  is  alkaline;  but  in  renal  tuberculosis  it 
remains  acid  until  pyogenic  infection  is  far  advanced.  Occurrence 
of  remissions  in  the  severity  of  the  symptoms  is  highly  characteristic 
of  tuberculosis,  but  is  unusual  in  renal  calculus.    In  the  latter,  exacer- 


TUMORS  OF   THE  KIDNEY  983 

bation  of  syinptonis  usually  follows  exercise;  but  in  renal  tuberculosis 
this  constant  relation  of  cause  and  efl'ect  is  not  seen.  Renal  calculus 
usually  may  be  excluded  by  skiagrai)liy.  In  tuberculosis  the  tempera- 
ture chart  (e\en  in  the  absence  of  pyogenic  infection)  should  recuse 
suspicion  of  tlie  nature  of  the  infection.  The  hypodermic  use  of  tuber- 
culin and  inoculation  experiments  with  the  centrifugated  urinary 
sediment,  are  valuable  aids  in  diagnosis.  Cystoscopy  usually  reveals 
appearances  around  the  ureteral  orifice  on  the  diseased  side  which 
are  considered  by  experts  highly  characteristic.  Ureteral  catheteri- 
zation is  the  surest  way  of  determining  the  healthy  condition  of 
the  second  kidney.  In  many  cases  inoculations  and  examinations 
of  the  urine  for  tubercle  bacilli  have  to  be  repeated  on  se\eral 
occasions,  as  the  results  are  not  always  constant. 

Treatment.— ]\Iost  surgeons  are  in  accord  in  recommending  removal 
of  the  diseased  kidney  as  the  only  hope  of  cure;  even  if  the  other  kidney 
is  slightly  diseased,  the  tuberculous  process  may  become  latent  in  it 
after  the  more  diseased  organ  has  been  removed.  The  excellent  efi'ect 
of  nephrectomy  on  vesical  tuberculosis  has  already  been  mentioned 
(p.  905).  The  immediate  mortality  of  nephrectomy  for  tuberculosis 
is  from  5  to  10  per  cent.;  and  about  26  per  cent,  of  patients  are  cured 
of  the  disease  and  remain  well  for  three  years  or  longer.  In  most 
others  great  improvement  occurs.  But  if  the  second  kidney  is  incom- 
petent, nephrectomy  should  not  be  done,  and  hygienic  treatment  alone 
must  be  employed.  If  pyonephrosis  is  present,  relief  may  be  afforded 
by  nephrotomy  and  drainage,  if  nephrectomy  is  contraindicated. 

Tumors  of  the  Kidney. — These  are  conveniently  classed  as  solid 
tumors  and  cysts. 

Solid  Tumors  of  the  Kidney. — Hypernephroma  is  the  commonest 
(p.  \'1~).  Other  solid  tumors  are  sarcoma  and  carcinoma.  Benign 
solid  tumors  are  very  rare.  Solid  tumors  occur  oftenest  in  adult  life, 
especially  from  forty  to  sixty  years  of  age;  but  sarcomas,  embryonic 
tumors  and  tumors  of  the  adrenal  gland  are  seen  in  children. 

The  physical  signs  of  all  these  solid  tumors  are  much  the  same, 
and  have  been  considered  under  the  differential  diagnosis  of  enlarge- 
ments of  the  spleen  (p.  953 j.  Hypernephroma  may  grow  to  immense 
size,  but  the  other  malignant  tumors  kill  before  they  reach  great  size. 
Symptomatic  varicocele  and  severe  referred  pain  are  usual  results,  and 
ascites  is  an  unusual  result  of  pressure  by  kidney  tumors.  The  chief 
characteristic,  apart  from  the  presence  of  a  tumor,  is  hematuria,  which 
often  is  painless,  usually  is  profuse,  and  occurs  without  vesical  S}mp- 
toms.  Bright  red  blood  is  passed  from  the  urethra  when  the  patient  ex- 
pects urine.  Bleeding  may  be  so  profuse  as  to  produce  faintness,  recurs 
at  irregular  intervals,  and  is  not  made  worse  by  exercise  as  is  the  less 
marked  bleeding  which  attends  renal  calculus.  If  the  ureter  is  blocked 
by  a  clot  the  urine  is  clear,  but  diminished  in  amount,  and  severe  pain 
may  be  felt  in  the  loin.  When  hemorrhage  occurs  and  back  pressure 
on  the  kidney  is  relieved  the  patient  may  feel  better.  Tumor  of  the 
adrenal  sometimes  may  be  distinguished  from  tumors  of  the  kidney 


984 


SURGERY  OF   THE  BLADDER  AXD  KIDXEYS 


proper  b>"  attention  to  certain  details:  it  is  most  frequent  in  children, 
and  anorexia,  listlessness,  loss  of  weight  and  strength  may  be  noted 
weeks  or  months  before  the  tumor  is  discovered;  the  tumor  grows 
beneath  the  diaphragm,  pushes  the  kidney  down,  causes  early  referred 
pain  and  paresthesia,  and  sometimes  is  accompanied  by  bronzing  of 
the  skin  and  precocious  puberty;  hematuria  is  very  rare.  The  skeleton 
always  should  be  examined  for  metastases. 

Prognosis. — H\"pernephroma  generally  leads  to  death  within  three 
of  four  years.  Sarcoma  and  carcinoma  terminate  fatally  within  a 
year  or  less,  as  do  tumors  of  the  adrenal  in  children. 

Treatment. — Nephrectomy  should  be  done  whenever  possible. 
If  the  growth  is  large  the  transperitoneal  route  is  the  best.  The 
immediate  mortality  of  operation  is  about  25  per  cent,  and  most 
patients  wlio  sur\-i\e  succumb  to  metastases  within  two  years. 

Cystic  Tumors  of  the  Kidney  are  rare  and  of  little  surgical  interest. 
Polycystic  disease  sometimes  appears  to  be  hereditary;  it  is  seen 
oftenest  in  early  infancy  or  in  middle  life;  usually  both  kidneys  are 
affected,  and  hence  nephrectomy  which  other'«-ise  would  be  proper, 
is  contraindicated.  Simple  serous  cysts  of  the  kidney  also  occur,  but 
are  exceedingly  rare. 

Injuries  of  the  Kidney. — Paipture  from  falls,  kicks,  etc.,  is  more 
frequent  than  stab  or  gunshot  wounds.  The  latter  are  recognized 
by  the  course  of  the  missile,  bleeding  into  the  bladder,  and  sometimes 

the  discharge  of  urine  from  the  wound. 
Subcutaneous  injury  varies  from  con- 
tusion, to  fragmentation,  or  complete 
disruption  (pulpef action;  of  the  kid- 
ney. There  is  hematuria,  and  in  most 
cases  a  hematoma  forms  in  the  flank. 
Intraperitoneal  hemorrhage  is  rare. 
There  is  much  local  pain  and  tender- 
ness, and  if  bleeding  is  profuse  or  long 
continued  even  in  small  amount  the 
usual  consequences  ensue. 

Treatment. — In  cases  of  gunshot  or 
stab    wound    the  kidney    should    be 
exposed    and    the   wound    tamponed 
or  closed  by  sutiu-e.     There  is   little 
prospect    of    spontaneous    arrest    of 
hemorrhage.      In    subcutaneous    in- 
juries,  on  the  other  hand,   bleeding 
frequently  ceases    when  the  patient 
is  kept  quiet  in  bed,  with  ice  locally 
and  morphin  internally.    Salol  or  uro- 
tropin  should  be  given.    If  bleeding 
is  very  profuse,  and  particularly  if  the  lumbar  hematoma  continues 
to  increase  in  size,  the   kidney  should   be  exposed  and  the  wound 
tamponed,  or,  better,  closed  with  mattress  sutures  of   chromic  gut, 


Fig.  914.— Rupture  of  right  kidney 
(anterior  ^■iew> .  Woman,  aged  thirty- 
two  years,  fell,  striking  loin  on  a  step. 
Operation  for  increasing  hematoma 
four  hours  after  injvuy.  Fragment 
sutured  to  kidney.  Recoven.-.  Epis- 
copal Hospital. 


OPERATIONS  OS   THE   KIDXEY 


985 


deeply  iiistTted  aiid  including  the  fibrous  ciij)suk'.  Xeplirect(jni\'  is  to 
be  avoided;  even  a  portion  of  the  kidney  completely  detached  may 
be  sutured  in  jjlace  (Tig.  1)14),  and  if  even  only  one-tenth  of  what 
is  saved  retains  its  functional  activity,  the  patient  is  just  so  much 
better  oil"  than  if  it  had  been  removed. 


OPERATIONS  ON  THE  KIDNEY. 

Position  of  the  Patient. — In  lumbar  operations  the  patient  should 
lie  prone,  with  a  sand-bag  or  other  support  between  the  costal  margin 
and  pelvis.  When  the  kidney  has  been  exposed  the  patient  may  be 
drawn  toward  the  foot  of  the  table,  while  the  sand-bag  is  kept  immov- 
able. Thus  it  compresses  the  lower  thorax,  enforces  abdominal  breath- 
ing, and  the  kidney  tends  to  prolapse  into  the  wound  (Edcbohls). 
In  the  abdominal  approach  the  position  is  similar  to  that  employed 
in  operations  on  the  bile-ducts,  but  with  the  patient  turned  a  little 
toward  the  healthy  side. 

Incisions. — The  usual  incision  for  lumbar  operations  runs  parallel 
to  the  last  rib,  and  about  an  inch  below  it,  from  the  outer  border  of  the 
erector  spinse  mass  for  four  or  five  inches 
downward  and  forward.  This  incision 
may  be  extended  forward  in  the  course 
of  the  motor  nerves  of  the  abdominal 
wall  (Fig.  915).  The  iliohypogastric 
and  ilioinguinal  nerves  lie  just  below 
this  incision  between  the  transversalis 
fascia  and  the  oblique  muscles,  and 
should  not  be  injured.  If  more  room  is 
desired  at  the  upper  angle  of  the  wound, 
the  lateral  arcuate  ligament  which  binds 
the  twelfth  rib  to  the  transverse  process 
of  the  first  lumbar  vertebra  and  the 
quadratus  lumborum,  may  be  cut  and 
the  rib  thus  mobilized.  By  keeping 
close  to  the  rib  there  is  not  much 
danger  of  wounding  the  pleura.  This 
oblique  incision  divides,  at  the  spinal 
end,  the  latissimus  dorsi;  at  the  ab- 
dominal end,  the  oblique  abdominal 
muscles  at  their  origin  from  the  lumbar 
aponeurosis.  This  aponeurosis  itself  is 
divided  as  far  backward  as  the  erector 

spina?  mass.  Then  the  transversalis  fascia  is  divided.  These  struc- 
tures are  shown  diagrammatically  in  Fig.  916.  When  they  have 
been  incised  the  peri-renal  fat,  enclosed  in  the  fascia  of  Gerota,  is 
exposed.  In  infected  cases  this  fatty  capsule  may  be  dense,  but  usually 
it  is  easily  displaced  by  the  finger,  exposing  the  kidney  covered  by  its 
true  capsule. 


Fig.  91.5. — Incision  for  exposure  of 
kidnev  bv  lumbar  route. 


986 


SURGERY  OF   THE  BLADDER  AND  KIDNEYS 


In  exposure  of  the  kidney  by  the  abdominal  route,  the  best  incision 
is  one  parallel  to  the  motor  nerves,  beginning  at  the  semi-lunar  line 
at  the  level  of  the  umbilicus  and  running  back  toward  the  flank  as 
far  as  necessary. 


Fig.  916. — Cross-section  of  left  lumbar  region,  to  show  structures  concerned  in 
operations  on  the  kidney  (diagrammatic).  1.  External  oblique  muscle.  2.  Internal 
oblique  and  transversalis  muscles.  3.  Latissimus  dorsi.  4.  Lumbar  aponeurosis.  5. 
Perirenal  fascia.     6.  Peritoneum.    7.  Ureter.     8.  Renal  artery.    9.  Renal  vein. 


Fig.  917. — Nephrotomy:  The  kidney  drawn  out  on  the  back  and  its  pedicle  com- 
pressed with  the  fingers.  The  splitting  of  the  kidney  here  shown  illustrates  the  operation- 
(Watson  and  Cunningham.) 

Nephrotomy. — After  exposure  of  the  kidney  by  a  lumbar  incision, 
as  indicated  above,  proceed  to  enucleate  it  from  its  fatty  capsule. 


OPERATIONS  ON   THE  KIDNEY  987 

Free  both  |)()les  as  well  as  the  anterior  and  posterior  surfaces  by  blunt 
dissection  with  the  finji;er,  and  do  not  atti^npt  to  deliver  the  kidney 
into  the  wound  until  it  has  been  thorouf^hly  freed.  In  infected  cases  it 
may  be  impossible  to  free  the  kidney,  on  account  of  adhesions;  hemor- 
rhage may  then  be  controlled  by  clami)ing  the  pedicle  with  rubber- 
covered  forceps  while  the  kidney  is  opened.  If  the  kidney  can  be 
delivered,  control  the  i)edicle  between  the  fingers  (Fig.  917).  Incise  it 
longitudinally  a  little  posterior  to  the  convex  border,  in  the  bloodless 
zone,  so  as  to  avoid  Brodel's  white  line  which  overlies  the  principal 
vessels  supi)lying  the  renal  cortex.  Brewer  opens  the  exposed  kidney 
by  Hilton's  method  (p.  51),  so  as  to  avoid  hemorrhage.  Cullen  uses  a 
wire  which  is  passed  from  one  pole  of  the  kidney  to  the  other,  and  is 
then  made  to  saw  its  way  out  through  the  convex  border. 

If  the  operation  is  for  the  removal  of  calculi  (nephrolithotomy) 
a  large  cortical  incision  is  desirable,  so  as  to  expose  all  the  calices 
and  the  pelvis  and  allow  probing  of  the  ureter.  If  the  operation  is 
done  merely  for  drainage,  the  opening  need  not  be  so  large. 

If  the  stones  are  known  to  lie  in  the  kidney  pelvis,  pyelotomy  shoul  d 
be  preferred  to  nephrolithotomy.  The  pelvis  is  exposed  by  turning 
the  kidney  forward  and  clearing  off  by  gentle  blunt  dissection  the  fat 
which  covers  the  posterior  surface  of  the  kidney  pelvis.  The  pelvis 
is  then  incised  a  short  distance  from  the  kidney.  After  removal  of 
calculi  and  probing  of  the  ureter,  the  fatty  tissue  overlying  the  pelvis 
is  sutured  back  in  place,  as  this  tends  to  prevent  leakage.  Drainage 
should  be  by  rubber  tissue,  not  by  gauze. 

Nephropexy  has  been  sufficiently  described  (p.  973). 

Nephrectomy. — The  kidney  is  exposed,  and,  if  possible,  is  delivered 
through  the  wound.  The  pedicle  is  attacked  from  below.  Clamp 
the  proximal  and  ligate  the  distal  portion  of  the  ureter,  cut  between, 
and  leave  the  ligature  long.  Expose  the  renal  arteries  and  vein  by 
blunt  dissection,  from  the  front  of  the  kidney;  if  not  too  bulky,  ligate 
the  pedicle  en  masse,  or  transfix  and  tie  on  both  sides.  Leave  the  liga- 
ture long.  Then  catch  the  pedicle  between  the  kidney  and  the  ligature 
in  forceps,  and  cut  between  the  kidney  and  the  forceps,  removing  the 
kidney,  but  leaving  the  forceps  on  the  pedicle,  In  case  bleeding 
occurs  (it  may  be  profuse)  the  pedicle  can  be  draw^n  into  the  W'Ound, 
and  another  ligature  applied.  If  it  is  impossible  to  expose  the  pedicle 
satisfactorily,  it  may  be  clamped  and  the  kidney  cut  aw^ay.  Never 
tie  the  ligature  while  the  clamp  is  in  place,  since  when  the  clamp  is 
released  and  the  pedicle  retracts  the  ligature  may  be  forced  off.  It 
is  permissible  to  hold  the  pedicle  in  a  clamp  while  the  ligature  is  being 
passed  (Fig.  918),  but  before  the  ligature  is  tied  the  clamp  must  be 
released.  If  this  is  impossible,  the  clamp  must  be  left  in  place  for 
four  or  five  days. 

The  kidney  being  removed  and  all  hemorrhage  checked,  the  liga- 
ture on  the  ureter  is  pulled  upon,  and  the  ureter  drawn  into  the  w'ound. 
As  much  as  possible  of  it  should  be  resected,  and  the  end  securely 
ligated.     In  septic  or  tuberculous  cases  it  is  weW  to  inject  10  drops 


988 


SURGERY  OF   THE  BLADDER  AND   KIDNEYS 


of  carbolic  acid,  thus  ensuring  obliteration  of  its  lumen.  In  cases  of 

nephrectomy  for  tuberculosis,  where  pyogenic  infection  is  absent,  it 

is  best  if  possible  to  close  the  wound  without  drainage.  In  all  cases 
of  pyogenic  infection  drainage  is  essential. 


Fig.  918. — Nephrectomy:  Manner  of  clamping  and  tying  the  pedicle  of  the 
kidney.      (Watson  and  Cunningham.) 

Closure  of  the  Wound. — In  all  operations  on  the  kidney,  whether 
drainage  is  employed  or  not,  the  same  care  in  suturing  the  wound 
should  be  taken  as  in  abdominal  operations.  Hernia  is  not  very 
infrequent   if   suturing   is   carelessly   done. 


CHAPTER  XXVI. 
VENEREAL  DISEASES. 

SYPHILIS. 

TiiK  path()lop;y  of  sypliilis   is   discussed   in   Chapter    III. 

Contagion.  The  disease  may  he  iiilicritcd  (coii^a-iiital  s\])liilis)  as 
well  as  aeciuired.  'i'lie  only  i)atli()lo»i{'al  dill'erence  hetween  these  two 
forms  of  the  disease  is  that  in  the  inherited  form  there  is  no  primary 
lesion  (chancre),  the  infecting  organism  having  entered  the  infant's 
body  through  its  mother's  blood  or  with  the  semen  of  the  father.' 
The  lesions  of  syphilis  from  which  the  disease  may  be  contracted  are 
the  primary  lesion  (chancre),  and  the  secondary  lesions  (especially 
mucous  patches).  Tertiary  lesions  seldom  if  ever  convey  the  con- 
tagion. In  nearly  all  cases  there  is  at  the  point  of  inoculation  a  pre- 
existing abrasion,  crack,  or  fissure  in  the  epithelium  of  the  patient 
inoculated;  inoculation  through  the  intact  skin  is  very  rare. 

The  occurrence  of  immediate  and  mediate  contagion  was  also  men- 
tioned in  discussing  the  pathology  of  syphilis.  In  most  cases  syphilis 
is  acquired  by  immediate  contagion,  during  sexual  intercourse. 
Hence  it  is  classed  as  a  ^'enereal  disease."  The  sores  from  which  the 
virus  is  derived  being  situated  on  the  genitalia,  the  sore  produced 
by  inoculation  likewise  develops  on  the  genitals.  If  the  disease  is 
not  contracted  during  coitus,  the  primary  lesion  usually  is  not  on  the 
genitalia  (though  it  may  be),  but  on  the  lip,  face,  or  other  exposed 
portion  of  the  body;  and  is  due  to  direct  contact  with  contagious 
sores  in  another  individual  (immediate  contagion)  or  to  mediate 
contagion  through  infected  towels,  eating  and  drinking  utensils,  etc. 
Such  patients  being  regarded  as  innocent,  the  disease  in  them  is  some- 
times termed  syphilis  insontium.  In  such  cases  mediate  contagion 
may  conceivably  cause  inoculation  in  the  genitalia;  but  the  presump- 
tion is  strong  that  a  genital  sore  has  been  acquired  during  the  venereal 
act.  Yet  it  is  well  to  remember  that  such  occurrences  are  at  least 
possible,  and  care  should  be  taken  not  to  wound  the  feelings  of  others 

'  It  has  not  been  found  possible  to  produce  a  similar  form  of  the  disease  experi- 
mentally (using  monkeys),  since  the  treponema  is  destroyed  by  phagocytosis 
when  injected  directly  into  the  blood.  According  to  Levaditi  and  Roche,  however, 
sj'jihilis  without  any  primary  lesion  has  been  produced  by  injecting  the  organisms 
into  the  testicle  where  they  are  able  to  develop.  In  these  cases  the  first  manifes- 
tations of  the  flisease  corresponded  to  secondary  syphilis,  and  in  so  far  resembled 
the  congenital  form. 

-  Until  Ricord,  in  1S36,  pointed  out  the  clinical  dififerences  between  chancre  and 
gonorrhea,  these  two  affections  were  not  distinguished,  both,  as  well  as  chancroid, 
being  considered  lesions  of  "the  venereal  disease"  (syphilis). 


990 


VENEREAL  DISEASES 


Fig.  919. — Multiple  chancres  (penis  and 
abdomen) ,  the  result  of  simultaneous  inocula- 
tion.    Episcopal  Hospital. 


and  perhaps  cause  domestic  iinhappiness  by  expressing  an  unguarded 
opinion,  whicli,  after  all,  may  prove  erroneous  (J.  Ashhurst,  Jr.). 

Symptoms  and  Diagnosis  of  Chancre. — A  chancre  develops  from 
three  to  five  weeks  after  exposure,  and  occurs  first  as  a  reddish-brown 
papule;  but  usually  when  first  seen  exfoliation  of  the  overlying  epithe- 
lium has  occurred.  The  chancre 
appears  as  a  superficial  erosion, 
which  is  common,  or  as  a  deep 
excavated  ulcer  (Hunterian 
chancre),  which  is  rare. 

In  the  male,  chancre  usually 
develops  on  the  prepuce,  fre- 
num,  or  glans  penis;  less  often 
on  the  body  of  the  penis,  the 
abdomen,  or  elsewhere.  In  the 
female  it  occurs  on  the  labia, 
within  the  vagina,  or  on  the  cer- 
vix uteri;  occasionally  around 
the  anus  or  in  the  perineum. 
In  men  it  usually  attracts  at- 
tention as  soon  as  it  develops, 
on  account  of  its  exposed  posi- 
tion; in  women,  for  the  contrary  reason,  it  is  generallyo  verlooked, 
and  they  come  under  treatment  first  when  secondary  lesions  develop. 

In  almost  all  cases  the  chan- 
cre is  solitary;  if  more  than  one 
is  present,  all  have  been  inocu- 
lated at  the  same  time,  usually 
from  numerous  secondary  le- 
sions (Fig.  919).  The  chancre 
is  not  auto-inoculable;  a  person 
who  has  a  chancre  has  de- 
veloped a  constitutional  disease 
which  runs  a  regular  course, 
and  he  is  immune  to  re-inocu- 
lation (from  his  own  sores  or 
sores  of  others)  until  the  dis- 
ease is  absolutely  eradicated. 
In  all  cases  the  chancre  is 
indurated,  at  some  time  in  its 
development.  Sometimes  in- 
duration appears  before  erosion 
of  the  epithelium  occiu-s,  and 
usually  it  persists  after  the  ulcer  has  cicatrized.  The  induration 
of  a  chancre  causes  it  to  feel  like  a  piece  of  parchment  or  a  split 
pea  in  the  skin,  and  often  the  chancre  can  be  picked  up,  as  it 
were,  without  causing  it  to  fold  on  itself  or  AATinkle  (Fig.  920).  _  In 
cases  where  induration  is  less  evident,  it  is  best  detected  by  slight 


Fig.  920. — Chancre,  duration  one  day;  ex- 
posure two  weeks  ago.  (Also  left  vari  cocele.) 
Age  twenty-one  years.  Note  induration.  Ulcer 
can  be  picked  up  in  forceps  without  folding 
on  itself.     Episcopal  Hospital. 


SYPHILIS 


991 


rigidity  of  the  prepuce  as  this  rolls  back  from  the  corona  glandis 

(Fig.  1)23).    This  is  not  an  inllannnatory  induration:  the  outlines  of  a 

chancre  (almost  invariably  round 

or  oval)  are  sharply  defined;  and 

there  is  no  redness,  heat,  swelling, 

or  abundant   secretion  from   the 

eroded  or  ulcerated  surface.     The 

surface  of  a  chancre  on  a  mucous 

membrane  may    be    moist,    and 

covered    with   a   thin    pellicle  of 

fibrin;    but  one  on    an   exi)ose(l 

surface  usually  is  covered  with  a 

dry  brownish  scab. 

The  duration  of  a  chancre  is 
self-limited.  It  heals  spontane- 
ously in  a  few  weeks  or  months 
unless  complications  arise.  It 
leaves  a  very  characteristic  cica- 
trix, which  usually  but  not  always, 
may  be  identified  years  later  by 
its  circular,  shiny,  slightly  de- 
pressed appearance  (Figs.  921 
and  922). 

A  mixed  chancre  is  a  sore  in  which  both  the  syphilitic  and  chancroidal 
viruses  have  been  inoculated.^    Usually  both  poisons  have  been  inocu- 


FiG.  921. — Scar  from  chancre  on  glans 
penis,  seven  months  previously.  Age 
twenty-two  years.  (Note  also  small 
punched-out  ulcer  back  of  prepuce  from  a 
healed  chancroid.)     Episcopal  Hospital. 


Fig.  922. — Scar  on  body  of  penis  from  chancre  two  years  previously.     Age 
twenty-six  years.     Episcopal  Hospital. 

1  Until  Bassereau  in  18.52  pointed  out  the  clinical  differences  between  chancre 
and  chancroid,  they  were  not  distinguished,  both  being  regarded  as  the  initial 
lesion  of  syphilis.  RoUet  in  1866  was  the  first  to  explain  the  essential  nature  of 
"mixed  chancre." 


992 


VENEREAL  DISEASES 


lated  at  the  same  time,  but  this  is  not  always  the  case.     A  chancre 
may  be  inoculated  subsequently  with  chancroidal  virus,  or  vice  versa. 


Fig.  923. — "Mixed  chaiierc."  Multiple  chancroids,  appeared  four  weeks  ago,  four 
day.s  after  coitus.  Induration  present  for  last  week  only.  Note  stiffness  of  prepuce 
as  it  is  rolled  back  from  corona  glandis.    Episcopal  Hospital. 

In  most  cases  the  early  symptoms  and  history  indicate  that  the  lesion 
is  a  chancroid;  and  it  may  be  only  when  the  ulcer  fails  to  heal  and 
induration  commences  (Figs.  923  and  924),  or  even  not  until  symptoms 

of  secondary  syphilis  appear,  that 
the  true  condition  is  recognized. 

Syphilitic  Bubo. — Very  soon  after 
the  appearance  of  the  chancre, 
the  related  lymph  nodes  (usually 
the  inguinal)  become  enlarged  and 
indurated.  INIany  nodes  are  af- 
fected {pohjgaiKjUonic),   and  if  the 


\\:i 


Fig.  924. — Mixed  chancre.  Lesion 
appeared  five  weeks  ago,  four  days  after 
coitus.     Episcopal  Hospital. 


Fig.  925. — Syphilitic  Iniboes.  Age  seven- 
teen years.  Coitus  January  1.5,  chancre  of 
glans  penis  developed  Feljruary  7.  Photo- 
graphed March  22,  1909.  Episcopal  Hos- 
pital. 


SYPHILIS 


993 


iiifiuinal  refjion  is  involved,  almost  invariably  the  alVection  is  bilateral. 
Usually  the  enlargement  is  moflerate  (Fig.  925),  but  oecasionally  I 
have  seen  great  lumps  the  size  of  oranges  develop.  The  individual 
nodes  do  not  tend  to  eoalesce,  they  remain  discrete;  their  outlines 
are  recognizable  on  palpation;  they  are  neither  especially  painful  nor 
very  tender;  they  show  no  evidences  of  acute  inflammation,  and  never 
suppurate.  These  features  serve  to  distinguish  syphilitic  from  chan- 
croidal bubo,  which  is  -unilateral,  infiainmatori/,  wry  painful;  and  in 
which  su}>puratio}i  is  frequent. 


Fig.  926.— Macular  syphiloderni ;  duration  m\<  n  days;  chancre  three  months 
ago.     Episcopal  Hospital. 

Symptoms  and  Diagnosis  of  Secondary  Lesions.—As  noted  in 
Chapter  III,  \ari()us  prodromal  symptoms  (fever,  malaise,  headache, 
vague  "rheumatic"  pains)  often  occur  during  the  period  between  the 
development  of  the  chancre  and  the  appearance  of  secondary  lesions. 
This  period  lasts,  on  the  average,  about  six  iceeks.  At  the  end  of  this 
time,  often  before  the  chancre  has  healed,  sometimes  after  its  existence 
has  iaeen  almost  forgotten,  and  occasionally  as  the  first  recognized 
63 


994 


VENEREAL  DISEASES 


symptom  of  syphilis  (the  chancre  having  passed  unnoted),  there  appear 
skin  rashes  which,  though  multiform  and  various,  possess  certain 
characteristics  by  means  of  which  their  syphilitic  nature  usually 
may  be  recognized.  About  this  same  time  the  lymph  nodes  all  over 
the  body  become  enlarged,  especially  the  posterior  cervical  and  epi- 
trochlear  groups.  This  lymphatic  involvement  is  very  characteristic, 
and  often  can  be  relied  on  for  diagnosis  when  the  skin  rashes  are 
too  faint  or  fleeting  for  recognition.      There  is  also  falling  of  the 

hair  (alopecia  syphilitica); 
and  sore  throat,  from  de- 
velopment in  the  pharynx 
of  lesions  which  correspond 
to  the  skin  rashes.  Affec- 
tions of  the  eye,  especially 
iritis,  sometimes  occur. 


Fig.  927.  —  Papular  sypliihxUrii],  .-caling 
(syphilitic  psoriasis):  duration  one  month; 
chancre  three  months  ago.  Episcopal  Hos- 
pital. 


Fig.  928.  —  Papulo-squamous 
syphiloderm ;  chancre  seven  months 
ago.     Episcopal  Hospital. 


The  occurrence  in  combination  of  skin  rashes,  lymphatic  enlarge-^ 
meni,  falling  of  the  hair,  and  sore  throat  is  almost  pathognomonic  of 
secondary  svphilis. 

Syphilodermas.— The  skin  rashes  of  secondary  syphilis  require  more 
extended  description.  They  are  characterized  (1)  by  the  so-called 
protean  nature  of  the  eruption,  or  the  appearance  simultaneously,  or 


svi'inLis 


995 


in  quick  succession,  or  more  than  one  variety;  (2)  by  their  appearance 
symnictricalh/,  all  over  the  body;  (3)  by  the  absence  of  .subject  ire  symp- 
toms, the  lesions  causing  no  sensation  of  itching,  burning,  etc.;  and 
(4)  by  the  ham-red  or  coppery  color  of  the  lesions,  especially  as  they 
fade  away.  Tiiey  are  distinguished  from  the  skin  lesions  of  tertiary 
syphilis:  (1)  by  their  appearance  within  a  more  or  less  definite  interval 
after  the  primary  lesion;  this  is  not  true  of  tertiary  lesions;  (2)  by 
their  general  and  symmetrical  distribution;  tertiary  skin  lesions  are 
local  and  asymmetrical;  (3)  they  do  not  spread  centrifugally  and 
hence  do  not  assume  the  circinate  and  serpiginous  character  of 
tertiary  lesions;  (4)  they  tend  to  disappear  spontaneously  after 
lasting  a  few  weeks  or  months,  even  without  treatment;  and  their 
disappearance  is  markedly  hastened  by  mercurial  treatment. 

Macular  rashes  (er\'thema  and  roseola)  usually  are  the  first  to  appear 
(Fig.  92());  they  may  become  apparent  only  after  the  patient's  body 
has  been  exposed  to  the  air.    Examination  in  a  good  light  is  necessary. 


Fu 


929. — Mucous  patches  around  the  labia  and  anus  of  a  colored  woman. 
Pennsylvania  Hospital. 


Papular  rashes  also  occur  early.  Papules  which  are  exposed  tend 
to  scale,  and  the  lesion  may  resemble  psoriasis  (Fig.  927).  A  papular 
eruption  which  occurs  late  is  more  deeply  situated  in  the  skin,  and 
bears  a  slight  resemblance  to  tertiary  lesions  (Fig.  928).  Papules 
which  occur  in  a  group  on  the  forehead,  just  below  the  hair  line,  tend 
to  become  confluent  and  are  termed  the  corona  Veneris.  Papules 
which  occur  on  mucous  membranes,  or  on  skin  surfaces  which  are 
moist  and  warm  (anus,  scrotum,  labia,  infra-mammary  folds)  have 
their  epithelial  covering  destroyed  by  maceration;  they  are  known  as 
mucous  patches,  or  if  confluent,  as  condylomata  lata  (Fig.  929).^    They 

1  The  condyloma  latum,  or  flat  wart,  is  so-called  to  distinguish  it  from  the  ordinary- 
venereal  wart  or  condyloma  acuminatum  (p.  1049). 


996  VENEREAL   DISEASES 

should  be  looked  for  in  the  situations  named,  as  well  as  in  the  buccal 
mucous  meml)rane  (cheeks,  palate,  fauces,  tonsils,  tongue). 

Pvstular  rashes  occur  later  than  the  macular  and  papular,  usually- 
several  months  after  the  primary  lesion.  The  chief  varieties  are 
ecthyma,  acne,  and  impetigo.  If  deep  ulcers  are  formed,  character- 
istic round,  white,  shiny  cicatrices  are  left. 

Symptoms  and  Diagnosis  of  Tertiary  Syphilis. — Usually  there  is 
an  interval  of  a  few  or  many  years  between  the  disappearance  of 
secondary  symptoms  and  the  occurrence  of  those  of  the  tertiary 
stage.  Occasionally,  however,  no  interval  elapses,  tertiary  symptoms 
appearing  wdiile  the  skin  rashes  of  the  second  stage  still  are  present. 
In  many  cases  no  tertiary  symptoms  ever  appear,  especially  if  active 
treatment  has  been  persisted  in  throughout  the  secondary  period. 

Tertiary  lesions  may  afl'ect  almost  any  tissue  in  the  body.  Those 
which  occur  in  the  skin,  mucous  membranes,  subcutaneous  tissues, 
eye,  nervous  and  vascular  systems,  muscles  and  fascia,  bones  and 
periosteum,  and  certain  of  the  solid  viscera,  are  of  most  importance 
in  surgery. 

The  skin  lesions  of  tertiary  syphilis  are  deep  and  destructive.  They 
appear  at  no  definite  interval  after  the  primary  lesion,  they  are  localized 
and  not  symmetrical  in  distribution,  they  tend  to  spread  centrifu- 
gally  and  to  assume  a  serpiginous  form,  they  show^  no  inclination 
toward  spontaneous  cure,  and  treatment  by  mercury  alone  rarely  is 
very  effective.  Their  chief  forms  are  the  tubercular  (not  tuberculous; 
see  p.  77),  sqvainous,  and  rupial. 

Syphilitic  tuhercules  are  at  first  reddish  or  coppery  papules,  which 
tend  to  early  ulceration;  as  those  in  the  centre  heal,  the  tubercules 
at  the  periphery  become  ulcerated,  producing  a  serpiginous  lesion 
(Fig.  930)  which  usually  is  easily  recognized.  Syphilitic  tubercules 
occur  frequently  about  the  eye  and  nose;  where  it  is  important  to 
distinguish  them  from  lupus,  and  rodent  ulcer.  The  scar  which 
results  from  a  tubercular  ulceration  is  large  and  quite  characteristic 
(Fig.  931);  it  will  be  noted,  in  the  patient  represented  in  this  photo- 
graph, that  although  both  knees  (symmetrical  portions  of  the  body) 
have  been  affected,  the  lesion  on  the  left  side  developed  seventeen 
years  after  that  on  the  right. 

Squamous  lesions  often  attack  the  palms  and  soles,  where  cracks 
and  fissures  are  frequent,  and  may  be  very  painful, 

Riqna  may  occur  in  one  or  many  patches,  following  a  bullous 
eruption  (Fig.  932). 

In  the  mucous  membranes  syphilitic  ulceration  may  cause  great 
destruction.  Gummatous  lesions  of  the  tongue  have  been  described  in 
Chapter  XIX.  The  palate,  fauces,  pharynx,  etc.,  may  suffer  severely; 
perforation  of  the  palate  is  not  unusual;  ''falling  in'  of  the  nose  is 
frequent;  and  sometimes  the  soft  palate  grows  fast  to  the  vault  of 
the  pharynx,  completely  shutting  off  the  nasal  passages  from  the 
oropharynx.  Strictures  of  the  esophagus,  larynx,  trachea,  and 
occasionallv  of  the  intestinal  canal  occur. 


svrjiiLis 


997 


In  the  subcutaneous  tissues  the  most  fr('([iiciit  k'sion  is  tlu'  sy])liilitic 
^Miimna  i  l-'ig. '.».!;i  i.  Its  cliiiiciil  cliaractiTS  liavc  hceii  (k'scrilu'd  in 
('liai)t(T  III. 

In  tlie  eye  the  most  frocinrnt   lesion   is  syi)liilitic   iritis. 

In  the  nervous  system  tho  lesions  ailect  chiolly  the  brain  and  spinal 
cord,  or  their  membranes.  Lesions  of  the  peripheral  nerves  are  rare. 
Any  lesion  of  the  central  nervous 
system  which  occurs  in  a  patient 
who  has  had  syphilis,  even  many 
.years  previously  (Fig.  934),  should 
be  regarded  as  syphilitic  until  the 
contrary  can  be  proved. 

In  the  arterial  system  the  in- 
fluence of  syphilis  in  causing  aneu- 
rysm has  been  pointed  out  in 
Chapter  X. 


Fig.  930. — Tuberculo-crustaceous  lesion,  in 
tertiary  stage  of  syphilis.  Duration  nine 
months.     Episcopal  Hospital. 


Fig.  931.  —  Left  knee,  active 
tubercular  ulceration  of  tertiary 
syphilis  in  a  woman  aged  fifty 
years,  twenty  years  after  the  pri- 
mary lesion.  Right  knee  and  thigh 
show  cicatrices  of  similar  tubercu- 
lar lesions  which  developed  seven- 
teen years  previously  and  were 
three  years  in  healing.  Episcopal 
Hospital. 


Fig.  932. — Syphilitic  rupia.     Age  twenty-six  years;  duration  five  weeks. 
Chancre  one  year  ago.     Episcopal  Hospital. 

In  the  muscles,  bursse,  tendons,  and  fascia  gummatous  tumors  are 
not  unusual,  limiting  function  by  their  bulk,  by  ulceration,  or  by 


998 


VMEREAL  DISEASES 


the  cicatrices  which  are  the  result  of  healing.  Syphilitic  panaris  and 
dactylitis  (P'ig.  935)  have  been  described  in  Chaj)ter  XIV. 

Syphilis  of  the  bones  has  been  considered  in  Chapter  XIV. 

Of  the  solid  viscera,  the  lesions  of  tertiary  syphilis  affect  particu- 
larly the  liver,  where  gummas  may  simulate  nodular  carcinoma.  The 
diagnosis  depends  on  the  history  of  the  case,  the  recognition  of  other 
signs  (past  or  present)  of  syphilis,  and  the  result  of  medication.  At 
operation  gummas  usually  may  be  recognized  by  central  softening, 
if  recent,  or  by  the  stellate  fibrous  cicatrix  which  results  when  heal- 
ing has  been  uninterrupted.  Excision  may  be  desirable  if  calcification 
occurs.  Syphilis  of  the  spleen  is  rare  and  of  little  surgical  interest. 
Syphilis  of  the  testicle  is  considered  in  Chapter  XXVIII. 


Fig.  933. — Gumma  of  neck  and  of  lower 
eyelid,  duration  six  weeks.  Patient  aged 
forty-five  years,  had  gonorrhoea  twenty- 
five  years  previously,  no  history  of  chan- 
cre. Rapid  improvement  under  mixed 
treatment.     Episcopal  Hospital. 


Fig.  934. — Paralysis  of  leftjjfacial 
nerve  from  intracranial  lesion,  thirty 
years  after  chancre.  Paralysis  of 
sudden  onset  ten  days  ago.  Epis- 
copal Hospital. 


Hereditary  Syphilis.— It  has  already  been  stated  that  this  differs 
from  the  acquired  form  of  the  disease  chiefly  in  having  no  primary 
lesion.  It  may  be  inherited  (1)  from  both  parents;  (2)  from  the  mother, 
infected  either  before  conception  or  during  pregnancy;  or  (3)  from  the 
father  at  the  time  of  conception.  As  the  mother  in  the  latter  cu-cum- 
stances  is  able  to  suckle  her  syphilitic  child  without  acquiring  syphilis 
herself  (Colles's  law,  1837),  it  was  formerly  taught  that  she  had  ac- 
quired immunity  from  the  fetus;  but  as  such  a  mother  reacts  positively 


SYPHILIS 


999 


to  the^Vilss(TIllilllll  test  (p.  1001 ),  it  is  now  tjiii^Mit  tliat  slie  has  iic(|nirefl 
syphilis  from  her  Ictus,  and  that  Iht  refractoriness  to  inoculation  is 
thie  to  the  fact  that  she  already  has  1  lie  disease,  t  hou.uii  in  latent  form. 
Profeta's  law  (hSO")),  to  the  cllcct 
that  a  healthy  child  of  syphilitic 
parents  is  unable  to  contract  syphilis, 
is  now  also  explained  by  the  child 
having  the  disease  in  latent  form, 
since  such  children  give  a  positive 
Wassermann  reaction.  Both  Colles's 
and  Profeta's  laws  are  merely  an 
expressit)n  of  the  fact  stated  at  jj. 
990,  that  any  patient  who  has  de\el- 
oped  syphilis  is  immune  to  re-inocu- 
lation until  the  disease  is  absolutely 
eradicated. 

Pregnancy,  in  the  case  of  syphilis, 
usually  terminates  in  abortion,  in  mis- 
carriage or  in  still-birth  at  term.  The 
more  attenuated  the  infection,  the 
more  probable  is  the  birth  of  a  living 
child  at  term.  The  child  often  shows 
no  evidences  of  syphilis  at  birth;  but  if  the  disease  is  truly  hereditary 
and  not  acquired  after  birth,  lesions  corresponding  to  those  of  the 
secondary  stage  almost  invariably  appear  before  the  age  of  two  weeks. 


Vie.  935. — Syphilitic  dactylitis,  in 
a  patient  aged  forty-one  years,  twelve 
years  after  chancre.  Episcopal  Hos- 
pital. 


Fig.  93G. — Hereditary  syphilis;  aged  twelve  years.     Hutchinson  teeth;  interstitial 
keratitis;  sabre-blade  tibiie.     Orthopa'dic  Hospital. 


1000 


VENEREAL  DISEASES 


The   earliesi   symptoms   are   bullous   skin   eruptions    (pemphigus), 
mucous  patches,  and  coryza  ("the  snuffles").    The  baby  suffers  from 


Fig.  937. — Saddle-nose  in  hereditary 
syphilis.  Age  twenty-four  years.  Also 
has  genital  infantilism  and  chronic  otitis 
media.     Episcopal  Hospital. 


Fig.  938. — Hereditary  syphilis.  Age 
fourteen  years;  superficial  gummata 
wrongly  diagnosed  as  tuberculosis  and 
eight  operations  done  during  last  five 
years.  (Dr.  W.  Walker's  case.)  Epis- 
copal Hospital. 


malnutrition  and  looks  wrinkled  and  prematurely  aged.    If  the  period 
of  infancy  is  survived,  further  lesions  seldom  appear  until  the  age 

of  six  years  or  older.  The  most 
characteristic  of  these  lesions  are 
i)itcrsiitial  krrattlis,  ''Hutchinson  s 
teeth''  (Fig.  936)  (a  peculiar  notched 
and  inverted  wedged-shaped  con- 
dition of  the  permanent  upper  cen- 
tral incisors,  first  recognized  as 
syphilitic  by  Jonathan  Hutchin- 
son, ISGl),  rhagades  or  linear  cica- 
trices at  the  corners  of  the  mouth, 
saddle-nose  (Fig.  937),  dactylitis, and 
sabre-blade  tibia  (Fig.  461).  Super- 
ficial gummata  may  be  mistaken 
for  tuberculosis  of  the  cervical 
lymph  nodes.  (Figs.  938  and  939) . 
Syphilis  of  the  joints  (p.  503)  is 
common  in  the  hereditary  form  of 
the  disease.  In  many  cases  genital 
Fig.  939.-Hereditary  syphilis,  same  infantilism  may  exist  even  if  the 
patient  as  Fig.  938,  three  months  after     bod^'  is  large  and  reasonably  well 

a   course   of    anti-syphilitic    treatment,      i?       "^    j 
Episcopal  Hospital.  lOrmeQ. 


sypiiiLis  1001 

Diagnosis  of  Syphilis. — This  has  been  based  for  many  years  solely 
on  tile  clinical  findings,  and  as  laboratory  aids  (particnlarly  the  coni- 
plieatcd  Wasserniann  test,  HH)())  often  are  not  available,  it  is  very  im- 
portant for  the  snr<;eon  to  be  able  to  reeofjnize  and  attach  due  sij^nifi- 
canee  to  the  multiform  symptoms  of  the  disease,  especially  as  these 
ofteii  are  de\('lo])ed  without  apparent  rej^ularitN'  and  are  constantly 
modified  l)y  previous  treatment  or  extraneous  circumstances.  Often 
very  little  assistance  can  be  obtained  from  the  patients  themselves, 
who  may  be  wilfully  deceptive  in  their  answers  or  who  may  really 
have  failed  to  notice  symptoms  sometimes  trivial  in  themselves  and 
frequently  sjjread  o\"er  a  lont:  term  of  years. 

The  distinction  between  chancre  and  chancroid  is  of  great  importance, 
and  usually  is  possible  clinically  by  attention  to  the  points  enumerated 
at  p.  1007;  but  the  existence  of  mixed  chancres  must  be  remembered, 
and  also  that  both  chancre  and  chancroid  may  be  inoculated  simul- 
taneously but  in  different  parts  of  the  body.  Moreover,  a  person 
already  having  syphilis  may  subsequently  acquire  a  chancroid,  and 
this  may  be  modified  by  the  syphilitic  soil  in  which  it  is  planted. 
Valuable  information  may  be  derived  from  "confrontation,"  or  the 
examination  of  the  individual  from  whom  the  disease  was  contracted; 
but  this  is  seldom  possible  in  this  country. 

Extragenital  Chancre,  particularly  on  the  lips  and  tongue,  must  be 
distinguished  from  carcinoma.  This  usually  may  be  done  clinically 
by  observing  the  early  palpable  enlargement  of  the  neighboring 
lymph  nodes  in  chancre,  and  the  effect  of  antisyphilitic  treatment. 
]\Iicroscopical  study  of  a  section  of  the  suspected  ulcer  is  a  sure 
method,  but  like  other  laboratory  aids  is  not  always  available. 

In  the  diagnosis  of  secondary  and  tertiary  lesions  the  surgeon  must 
rely  not  upon  any  one  or  two  symptoms,  but  upon  the  coexistence  of 
a  number,  and  especially  upon  their  course  and  order  of  development. 
A  surgeon  meeting  with  a  case  of  iritis  or  of  cutaneous  eruption,  or 
of  periosteal  "rheumatism,"  in  a  person  of  notoriously  lax  morality, 
should  not  at  once  jump  to  the  conclusion  that  the  disease  is  syphilitic; 
for  to  do  so  would  be  as  unphilosophical  as  it  might  be  unjust.  If, 
on  the  other  hand,  a  patient  should  suffer  from  frequent  attacks  of 
recurrent  iritis,  copper-colored  eruptions  of  various  forms,  post-cervi- 
cal engorgement,  alopecia,  and  occasional  development  of  mucous 
patches;  or  from  osteoscopic  pains,  indolent  nodes  and  gummatous 
tumors  of  the  areolar  tissue — even  though  such  a  patient  should  appear 
as  virtuous  as  Joseph  or  as  wise  as  Penelope — the  surgeon  might 
reasonably  conclude  that  he  had  to  deal  with  a  case  of  syphilis,  and 
should  direct  his  remedies  accordingly  (J.  Ashhurst,  Jr.). 

Laboratory  Aids  to  Diagnosis. — In  many  of  the  ulcerated  lesions  of 
syphilis,  especially  the  chancre  and  mucous  patches,  it  is  possible  to 
find  the  Treponema  pallidum  by  microscopical  study  of  smears  with 
dark  field  illumination,  or  after  proper  staining.  The  Wassermann 
or  complement-fixation  test  for  syphUis  is  now  in  almost  universal 
use,  and  is  considered  perfectly  reliable  within  certain  limits.     The 


1002  VENEREAL  DISEASES 

test  is  of  highly  technical  nature,  and  requires  long  practice  and  vast 
experience  for  its  proper  performance;  many  of  the  tests  are  useless 
because  these  exacting  conditions  are  not  fulfilled.  Then  the  test 
sometimes  is  not  positive  during  the  earliest  stage  of  syphilis  (chancre), 
nor  as  a  rule  during  the  secondary  stage  if  the  patient  has  been  under 
active  antis^'philitic  treatment.  It  is  of  greatest  value  in  the  third 
stage  of  the  disease,  and  in  para-syphilitic  affections,  since  here  the 
patient  usually  has  not  been  under  active  treatment  for  a  long  time, 
and  if  the  test  is  positive  it  may  be  considered  conclusive  evidence 
that  the  patient  is  still  suffering  from  syphilis.  Even  this  does  not 
prove,  however,  that  the  lesion  in  question  is  necessarily  s}"philitic. 
In  the  case  of  hereditary  syphilis,  also,  a  positive  Wassermaun  reac- 
tion may  indicate  that  a  chUd  of  syphilitic  parents  is  itself  actively 
infected,  or  it  may  indicate  merely  that  the  child  has  syphilis  in  a 
latent  form,  in  accordance  with  Profeta's  law.  Whether  or  not  a 
positive  Wassermami  test  may  be  obtained  in  the  third  or  fotu-th 
generation  of  patients  suffering  from  latent  s\'philis  is  not  certain; 
but  I  am  inclined  to  believe  that  it  may.  Certainly  the  fact  that  the 
test  is  positive  often  is  the  only  evidence,  however  remote,  which  can 
be  obtained  to  indicate  that  the  patient  or  his  ancestors  ever  were 
infected  with  syphilis. 

Treatment  of  Syphilis.' — As  s\-phihs  is  a  general  infection,  consti- 
tutional treatment  is  much  more  important  than  local.  It  has  been 
found  by  several  centuries  of  experience  that  the  most  useful  internal 
remedies  are  mercury  and  the  iodides.  The  first  of  these  is  antiseptic, 
and  probably  acts  directly  on  the  parasite  which  causes  the  disease, 
thus  being  specially  indicated  during  the  active  stages  of  s^-philis; 
while  the  iodides,  which  aid  elimination,  are  chiefly  beneficial  (either 
alone  or  combined  with  mercury)  in  the  tertiary  stage.  Since  the  dis- 
covery of  the  microbic  cause  of  s\-philis,  renewed  efforts  have  been 
made  to  secure  some  drug  which  shall  once  and  for  all  destroy  the  para- 
sites which  cause  the  disease  and  thus  produce  rapid  cure.  At  first 
it  was  thought  that  this  Sterilisatio  Magna  had  been  provided  in  the 
arsenical  compound  known  as  Salvarsan,  the  six  hundred  and  sixth 
("606")  chemical  s^Tithetically  prepared  by  Ehrlich,  with  this  end 
in  view,  and  fiu-nished  to  the  pubUc  in  1909.  To  this  remedy  has 
succeeded,  lately,  neosaharsan.  But  it  has  become  evident  that  while 
these  preparations  are  of  exceedingly  great  efficacy  in  certain  cases, 
their  use  only  supplements  and  does  not  supplant  that  of  mercm-y 
and  the  iodides. 

Tliroughout  the  continuance  of  the  disease,  strict  rules  of  hygiene 
must  be  observed.  In  alcoholics,  nephritics,  and  the  tuberculous, 
the  prognosis  is  bad.  In  otherwise  healthy  patients  the  disease  is  not 
only  curable,  but  often  rapidly  so.  The  patient  must  not  drink  any 
alcoholic  liquors.  He  mtist  not  smoke  nor  chew  tobacco,  as  these 
habits  favor  the  development  of  mucous  patches.    He  should  have  his 

^  The  question  of  venereal  prophylaxia  is  mentioned  at  p.  1011. 


SYPHILIS  1003 

tcetli  i)ut  into  ,i:;()()(l  onk-r,  and  sluuild  keep  tliciii  in  ^ood  coiiditioii 
throiigliout  the  disease,  lie  must  take  <;reat  care  of  his  skin,  l)athing 
frequently  and  paying  special  attention  to  regions  where  mucous 
patches  are  apt  to  develoj).  He  nuist  be  careful  in  liis  diet,  lie  must 
not  kiss  any  one  on  the  lips;  nuist  sleep  alone;  nuist  never  use  a  common 
towel,  drinkini;'  cu]),  or  other  utensil  likely  to  sj)read  contagion. 

Treatment  of  the  First  Stage.  -Unless  the  diagnosis  of  chancre  is 
positive,  1  believe  it  is  improper  to  administer  constitutional  treat- 
ment until  the  appearance  of  secondary  symptoms  renders  the  exist- 
ence of  syi)hilis  certain.  The  reason  for  this  is  that,  if  the  sore  is  not  a 
chancre,  no  secondary  symptoms  will  appear  under  any  circumstances, 
and  if  the  sore  is  wrongly  suspected  of  being  a  chancre,  and  consti- 
tutional treatment  is  administered,  the  subsequent  failure  of  secondary 
symptoms  to  ap])ear  may  be  attributed  to  the  treatment  employed, 
and  both  physician  and  patient  will  still  entertain  the  erroneous  opinion 
that  syphilis  is  present.  Hence  is  apparent  the  extreme  importance 
of  reaching  an  accurate  diagnosis  in  the  first  stage  of  the  disease, 
by  careful  clinical  study  and  laboratory  work. 

If  in  any  manner  the  diagnosis  of  chancre  is  incontestable,  then  the 
patient  should  be  put  upon  constitutional  treatment  at  once,  since 
there  is  very  little  doubt  that  this  will  render  the  subsequent  course 
of  the  disease  less  severe.  The  best  way  to  administer  mercury  inter- 
nally is  in  the  form  of  the  protiodide  (hydrargyri  iodidum  flavum) 
in  doses  of  from  |  to  j  grain  (0.008  to  0.016  gram).  The  tolerance  of 
the  patient  for  this  drug  must  be  ascertained,  and  the  dose  must 
be  kept  just  below  this  point.  Usually  it  is  well  to  combine  a  tonic, 
such  as  iron,  with  the  mercury.  Whenever  mercury  is  being  taken 
the  patient  should  be  directed  to  snap  his  teeth  together  occasionally, 
to  ascertain  the  first  occurrence  of  tenderness  of  the  gums;  the  dose 
is  then  reduced  slightly.  Should  salivation,  unfortunately,  occur,  the 
drug  must  be  stopped  at  once,  and  cleansing  mouth  washes  used. 

Locally,  little  need  be  done  for  the  chancre,  beyond  keeping  it 
clean  and  dusting  it  occasionally  with  some  inert  powder.  Cauteriza- 
tion is  not  only  useless  but  harmful;  and  the  uselessness  of  excision 
with  a  view  of  arresting  the  disease,  was  pointed  out  in  Chapter  HI. 
If  the  buboes  which  attend  a  chancre  are  painful,  they  may  be 
covered  with  ichthyol  or  belladonna  and  mercury  ointment,  and 
slight  pressure  may  be  applied  by  a  firm  bandage. 

Treatment  of  the  Second  Stage. — If  constitutional  treatment  has  been 
begun  in  the  first  stage,  no  secondary  manifestations  may  appear; 
but  it  will  still  be  necessary  to  continue  treatment  since  experience 
has  shown  that  not  only  may  its  discontinuance  be  followed  by  the 
appearance  of  secondary  lesions,  but  that  the  occurrence  of  tertiary 
lesions  is  more  certain  and  their  character  more  severe,  while  after 
prolonged  and  proper  treatment  during  the  second  stage  they  usualh' 
are  mild  if  they  appear  at  all.  A  continuation  of  the  internal  adminis- 
tration of  mercury  is  the  least  distasteful  treatment  for  the  patient, 
and  if  the  protiodide  has  been  given  successfully  during  the  first  stage 


1004  VENEREAL  DISEASES 

it  may  be  continut'd  iiiti)  the  second;  or  wliat  is  probaMy  l)etter,  the 
bichloride  or  the  binicxUde  of  mercury  (hydrargyri  iodidum  rubrum) 
may  be  given  in  doses  of  from  ^  to  g  grain  (0.004  to  0.008  gram), 
three  times  daily  in  pill  form.  If  a  tonic  seems  indicated,  a  mixture 
may  be  made  up  with  the  compound  tincture  of  gentian,  the  com- 
potmd  syrtip  of  sarsaparilla,  or  the  tincture  of  the  chloride  of  iron. 

If  the  patient  first  comes  under  treatment  when  the  second  stage  is 
fully  developed,  there  is  no  better  method  to  gain  prompt  control  of  the 
symptoms  than  by  inunctions  of  mercury;  indeed,  I  much  prefer  this 
method  of  administration  in  all  cases,  but  patients  often  object  to  it 
as  imcleanly.  About  a  dram  of  the  L'nguentum  Hydrargyri  is  to  be 
rubbed  into  a  non-hairy  part  of  the  body  once  daily.  The  same  part 
of  the  body  should  not  be  employed  again  except  after  an  interval 
of  several  days:  this  is  accomplished  by  using  in  succession  the  two 
sides  of  the  thorax,  the  two  flanks,  and  the  epigastrium.  The  patient 
should  make  the  inunctions  himself;  if  made  by  another,  gloves  should 
be  worn  to  prevent  absorption  through  the  hands.  The  patient 
should  wear  the  same  underclothing  for  a  week  before  bathing  and 
removing  the  excess  of  mercury.  When  the  symptoms  are  thoroughly 
under  control  Tusually  within  a  few  weeks)  inunctions  may  be  dis- 
carded if  the  patient  desires,  and  mercury  may  be  administered  by 
mouth,  as  above  described.  Should  active  symptoms  recur,  it  is  best 
to  resume  inunctions  temporarily. 

The  hypodermic  administration  of  mercury  salts  has  been  tried  but 
abandoned  by  most  who  were  at  one  time  enthusiastic  advocates 
of  the  method.  It  has  been  fotmd  painful,  dangerous,  and  unreliable. 
Intramuscular  injections  are  hotly  advocated  by  E.  L.  Keyes,  Jr.; 
he  prefers  a  mixture  of  hydrarg\Ti  salicylatis  3  parts,  and  alboline 
(or  benzinol)  30  parts.  From  5  to  10  cgm.  are  injected  once  or  twice 
weekly  into  the  gluteus  maximus.  Mercurial  fumigations  are  used 
by  some,  but  never  have  been  widely  adopted. 

Administration  of  mercury  in  some  form  should  be  continued  at 
least  for  two  years  and  a  half  after  the  initial  lesion.  Some  follow 
the  intermittent  method:  give  mercury  for  six  months,  then  stop 
for  a  month;  then  give  it  for  three  months,  then  stop  for  two  months. 
This  includes  the  first  year.  During  the  second  year  mercury  is  given 
for  eight  months  at  intervals.  Continuous  administration  is  prefer- 
able; and  after  cessation  at  the  end  of  two  and  a  half  or  three  years, 
the  administration  of  mercury  should  be  resumed  if  symptoms  recur, 
or  if  a  positive  Wassermann  reaction  develops;  and  should  then  be 
continued  at  intervals  until  this  reaction  remains  constantly  negative, 
even  after  treatment  has  been  stopped  for  some  months. 

Treatment  of  the  Third  Stage. — Here  the  iodides  should  be  taken, 
usually  in  combination  with  mercury,  which  markedly  enhances 
their  effectiveness.  Potassium  or  sodium  iodide  may  be  given  in 
doses  beginning  with  5  or  10  grains,  thrice  daily,  and  increased  to  a 
point  just  short  of  iodism.  In  deep  lesions,  especially  of  bone,  immense 
doses  are  tolerated.    Local  treatment  of  external  lesions  in  this  stage 


CHANCROID  11)05 

is  an  iiiiportnnt  adjmiint  to  constitutional  treat tncnt,  l)Mt  without 
the  hitter  is  ahsohitely  inefficient. 

Treatment  of  Hereditary  Syphilis. — If  eitlier  i)arent  is  syphilitic 
the  mother  shouhl  be  treated  (hiring  pregnancy.  Tiiis  reduces  the 
chance  of  miscarriage,  and  favorably  influences  the  course  of  the  dis- 
ease in  tlie  chihl  Treatment  of  the  mother  shouhl  be  continued 
throughout  lactation  for  the  infant's  sake,  quite  apart  from  any 
indication  for  treatment  on  her  own  part.  Inunction  is  the  safest 
and  surest  method  of  administering  mercury  to  the  baby;  a  few  grains 
of  blue  ointment  may  be  spread  on  the  infant's  binder,  daily,  and 
allowed  to  work  its  way  into  the  skin  by  the  baby's  movements.  For 
later  lesions  (bones  and  joints)  iodides  also  should  be  given.  In  most 
cases  tonics  are  indicated,  especially  iron  and  quinine. 

Treatment  of  Syphilis  by  Salvarsan. — This  is  a  powerful  antiseptic, 
and  ra])idly  kills  any  syphilitic  parasites  with  which  it  is  brought  into 
direct  contact.  It  has  no  eliminative  action  like  the  iodides,  and  is 
useless  for  lesions  to  w^hich  it  cannot  be  conveyed  directly  through 
the  blood-stream.  It  is  administered  by  intravenous  injection.  The 
usual  dose  is  0.6  gm.,  in  40  c.c.  of  freshly  prepared  and  sterile  physiologi- 
cal salt  solution.  This  mixture  is  rendered  alkaline  by  adding,  drop 
by  drop,  1  c.c.  of  a  15  per  cent,  solution  of  sodium  hydrate,  constantly 
agitating  the  mixture.  Then  enough  salt  solution  is  added  to  make 
300  c.c.  Thus  each  50  c.c.  of  the  entire  mixture  contains  0.1  gm.  of 
salvarsan. 

Though  occasional  deaths,  and  a  few  cases  of  blindness  and  serious 
lesions  of  the  central  nervous  system  have  been  recorded  as  following 
its  use,  and  presumably  caused  by  it,  no  hesitation  need  be  entertained 
in  its  employment  in  any  case  where  a  rapid  amelioration  of  symptoms 
is  imperative.  That  it  is  absolutely  curative  in  some  cases  is  indicated 
not  alone  by  the  sudden  and  permanent  disappearance  of  all  symptoms, 
but  also  by  the  persistently  negative  Wassermann  tests,  and  in  a  few 
instances  by  the  fact  that  patients  have  lost  their  immunity  to  syphilis 
and  have  again  acquired  the  disease.  In  most  cases  it  is  necessary 
to  continue  the  use  of  mercury  and  the  iodides  after  the  injection 
of  salvarsan,  even  if  this  has  been  repeated  one  or  more  times,  as  it 
mav  be  at  intervals  of  not  less  than  one  week. 


CHANCROID. 

The  Chancroid,  or  Ulcus  Molle  (to  distinguish  it  from  the  syphilitic 
chancre  or  ulcus  durum),  is  now  generally  believed  to  be  caused  by 
infection  with  the  Bacillus  of  Ducrey  (1889).  According  to  Sovinsky 
(1904)  a  pure  culture  of  this  bacillus  will  produce  chancroids  in  man 
and  in  animals.  The  infection  is  strictly  local,  and  always  is  acquired 
by  inoculation  from  a  similar  sore.  Usually  it  is  acquired  in  coitus,  but 
mediate  transmission  is  possible.  The  lesion  is  auto-inoculable;  from 
its  first  appearance  and  so  long  as  it  remains  unhealed,  other  chancroids 


1006 


VENEREAL  DISEASES 


may  l)e  inoculated  from  the  pus  which  flows  over  the  surrounding 
skin. 

Chancroid  occurs  oftenest  on  the  genital  organs — especially  on  the 
prepuce,  corona  glandis,  frenum,  and  urinary  meatus  in  the  male; 
and  in  the  female  on  the  labia  or  os  uteri.  But  any  part  of  the  body 
exposed  to  the  contagion  may  be  inoculated.  It  is  not  very  rare  for 
inoculation  to  occur  through  unbroken  skin;  but  usually  some  minute 
abrasion  or  excoriation  is  already  present. 

Clinical  Course  and  Symptoms. — There  is  no  distinct  period  of 
incubation.  Usually  the  next  day  after  exposure  the  patient  feels  an 
itching  or  tingling  at  the  point  of  inoculation;  a  minute  papule  rapidly 
forms,  and  this  in  another  day  becomes  a  vesicle,  then  a  pustule 
which  either  ruptures  and  exposes  an  ulcer,  or  becomes  scabbed. 
Thus  by  the  fourth  to  sixth  day  the  lesion  is  fully  developed.  An  ulcer 
which  appears  later  than  the  tenth  day  after  exposure  is  not  a  chan- 
croid. In  about  80  per  cent,  of  cases  multiple  chancroids  are  present. 
These  may  have  been  inoculated  simultaneously,  or  may  have  been 
inoculated  one  after  the  other  from  the  single  original  lesion. 

A  chancroid  appears  as  a  rounded  or  oval  ulcer,  apparently  punched 
out  of  the  skin,  with  sharply  defined  and  undermined  margins  (Fig. 
924).  It  varies  in  size  from  less  than  0.5  cm.  to  1.5  cm.  in  diameter; 
it  is  not  adherent  to  the  underlying  tissues,  is  surrounded  at  first  by 
a  reddened  area  of  inflammatory  reaction,  discharges  profusely  pus 
which  is  auto-inoculable,  and  is  covered  by  an  adherent  grayish  slough. 
There  is  a  certain  amount  of  inflammatory  induration  about  the  base 
of  a  chancroid,  but  it  is  not  sharply  limited  and  does  not  resemble 
the  parchment-like  induration  so  characteristic  of  triie  chancre. 


Fig.  940. — Left  intruinal  bubo,  one  week  after  development  of  chancroid  on  frenum. 
No  bacillus  of  Duerey  found  in  pus,  and  bubo  healed  promptly  after  incision.  Episcopal 
Hospital. 


Chancroidal  Bubo. — In  many  cases,  but  not  in  all,  the  related  lymph 
nodes  become  inflamed,  and  suppuration  is  very  frequent.  This 
complication  usually  develops  within  the  first  two  weeks,  but  occasion- 
ally not  for  several  weeks  after  the  chancroid  has  healed.    Suppura- 


CHANCROID  1007 

tioii  in  the  l)ul)()  luuy  result  from  secoiulury  infection  of  tiie  cliancroid 
with  pyogenic  microbes  (the  bubo  being  then  similar  to  the  ordinary 
huhon  (Vi'm})lf'C,  p.  209),  or  may  de  (hic  to  direct  al)sorption  through 
the  lymphatics  of  the  Jiacillus  of  Ducrey.  Absorption  of  toxins 
produced  by  this  bacillus  is  not  a  sufhcient  explanation.  It  is  believed, 
however,  that  the  Bacillus  of  Ducrey  is  self-destroyed  by  the  toxins 
it  produces  in  the  })ubo,  and  this  is  held  to  explain  the  difficulty  of 
obtaining  cultures  or  smears  of  tiie  organism  from  the  abscess. 

A  chancroidal  bubo  almost  always  is  unilateral  (Fig.  940),  usually 
on  the  same  side  of  the  body  as  the  chancroid  itself.  It  is  distinctly 
inflammatory  in  character  from  the  first,  and  in  no  way  resembles 
the  indolent  syphilitic  bubo  in  which  many  separate  lymph  nodes  are 
palpable. 

Phagedenic  Ulceration  occasionally  occurs  in  chancroid,  especially 
in  patients  who  are  in  poor  constitutional  condition  from  alcoholic 
or  venereal  excesses,  or  who  are  tuberculous.  Serpiginous  ulceration 
also  is  rare;  usually  it  is  seen  in  the  case  of  inguinal  buboes  which  have 
been  opened  without  due  attention  to  cleanliness,  and  have  become 
secondarily  infected  with  the  discharges  from  the  original  chancroid 
(Fig.  942). 

Other  complications  are  phimosis,  para- phimosis,  balanoposthitis, 
coc.risfencc  of  syphilis  or  of  gonorrhea,  etc. 

Diagnosis  of  Chancroid. —  Herpetic  eruptions  on  the  genitalia 
develop  almost  immediately  after  coitus,  do  not  form  ulcers  by  the 
third  or  fourth  day,  but  disappear  spontaneously.  They  are  not 
auto-inoculable.  Yet  a  chancroid  may  develop  in  an  herpetic  vesicle, 
and  therefore  a  distinction  before  the  third  or  fourth  day  is  not  always 
possible.  A  chancre  appears  about  three  weeks  after  coitus,  not  within 
a  few  days;  it  is  single,  unless  multiple  from  the  first,  whereas  chan- 
croids usually  are  multiple  even  if  single  at  first.  A  chancre  is  a  super- 
ficial erosion  or  an  ulcer  with  hard,  elevated,  sloping  edges,  not  a 
punched-out  ulcer  with  undermined  edges;  it  presents  a  peculiar 
parchment-like  induration  and  is  not  surrounded  by  a  reddened 
inflammatory  base;  it  is  almost  invariably  accompanied  by  double 
inguinal  bubo,  which  rarely  if  ever  suppurates,  while  chancroid  often 
has  no  bubo  and  if  one  occurs  it  Is  unilateral  and  almost  always  sup- 
purates; a  chancre  has  an  innate  tendency  to  heal  but  is  followed  by 
constitutional  symptoms  of  syphilis,  while  a  chancroid  has  no  innate 
tendency  to  heal  and  is  never  followed  by  syphilis  unless  a  mixed 
chancre  (p.  991)  is  present.  One  attack  of  chancroid  aftords  no  pro- 
tection against  subsequent  attacks. 

Treatment  of  Chancroid. — Some  mild  chancroids  may  heal  under 
ordinary  antiseptic  dressings.^     It  is  possible  ,  however,  that  such 

1  T.  R.  Xeilson  recommends  the  following: 

I^ — Hydrargyri  chlorid.  corros.,  gr.  | 

Zinci  sulphat.,  gr.  ix 

Acid,  boric,  3    j 

Glycerini,  3     iij 

Aquse,  f5   vj 

M. — S. — Apply  on  absorbent  cotton. 


1008 


VENEREAL  DISEASES 


sores  are  not  true  chancroids  but  only  herpetic  ulcerations  infected 
by  pyogenic  cocci.  In  most  chancroids  the  surest  and  occasionally 
the  only  way  to  secure  healing  is  to  destroy  the  specific  microbes  by 
cauterization.  For  this  purpose  I  have  never  found  anything  so 
efficient  as  fuming  nitric  acid.  Some  surgeons  much  prefer  carbolic 
acid,  or  even  the  actual  cautery.  If  the  chancroid  is  large,  or  the 
patient  very  timid,  it  may  be  necessary  to  administer  an  anesthetic. 
But  in  the  average  dispensary  case  (and  it  is  only  in  the  lowest  class 
of  such  patients  that  chancroids  are  seen — it  is  a  disease  of  filth)  no 
anesthetic  is  necessary.  Cauterization  should  not  be  employed  unless 
the  diagnosis  is  certain;  it  produces  induration  and  makes  difficult 
a  distinction  from  the  initial  lesion  of  syphilis.  When  it  is  employed, 
thoroughness  is  requisite.  The  best  way  to  apply  nitric  acid  is  by 
means  of  a  stick  about  the  size  of  a  pencil  smoothly  rounded  off  at  one 
end.  The  surrounding  healthy  skin  should  be  protected  from  the  acid 
by  smearing  it  with  olive  oil  or  vaselin,  and  the  ulcer  is  dried.  The 
stick  is  then  dipped  in  the  acid,  and  is  \'igorously  rubbed  into  the 
ulcerated  surface,  overlooking  no  corner  or  cranny.  This  destroys 
the  specific  microbes,  and  when  the  resulting  crusts  separate  it  will 
be  found  that  a  healthy  granulating  surface  is  left  which  will  soon 
heal  under  ordinary  antiseptic  dressings  or  ointments.  If  healing 
does  not  proceed  normally,  cauterization  must  be  repeated,  but  this 
is  very  seldom  necessary  if  it  has  been  properly  done  in  the  first 
place. 


Fig.  941. — Dorsal  slit  of  prepuce  to  expose  chancroids  of  mucous  surface  of  prepuce. 
Note  inflammatory  thickening  of  prepuce.     Episcopal  Hospital. 


If  the  chancroitl  is  inaccessible  on  account  of  phimosis,  the  foreskin 
should  be  slit  up  the  dorsum  (Fig.  941),  under  cocain;  then  the  cut 
edges  and  the  exposed  chancroids  are  to  be  cauterized.  I  have  never 
seen  a  case  where  an  efficient  dorsal  slit  did  not  give  enough  exposure. 

Treatment  of  Chancroidal  Bubo. — It  is  useless  to  attempt  to  treat 
the  bubo  until  the  infecting  focus  (chancroid)  has  been  cured,. since 
fresh  inoculation  will  constantly  occur  through  the  lymphatics. 
Prompt  treatment  of  the  chancroid  itself,  as  indicated  above,  fre- 


GONORRHEA  1(X)9 

(liK'iitly   is   siiffick'Ut   to   cause   the    hulx)   to  disappear,   even   when 
suppuration  aj)pears  to  threaten. 

I  (h)  not  think  it  is  advisable  to  open  a  ehancroichil  l)ul)0  until 
suppuration  is  very  evident;  the  lonj^er  the  pus  remains  in  the  abscess, 
the  more  apt  it  is  to  steriHze  itself  of  the  chancroidal  virus.  Yet 
spontaneous  rupture  of  the  abscess  is  to  be  avoided  at  all  hazards, 
especiall\-  if  the  chancroid  itself  is  unhealed;  since  then  the  opened 
bubo  will  become  infected  by  the  discharges  from  the  chancroid,  and 


Fig.  942. — Chancroidal  ulcer.  Age  fifty-five  \i  ;-.  Iiuration  ten  weeks.  Bubo 
developed  soon  after  chancroid  of  glans,  and  was  allowed  to  rupture  spontaneously; 
the  ulcer  then  became  infected  with  the  chancroidal  virus,  and  showed  no  tendency  to 
heal.    Treated  by  excision.    Episcopal  Hospital. 

will  be  converted  into  a  chancroiflal  ulcer  (Fig.  942).  When  the  bubo 
is  to  be  opened,  this  should  be  done  with  careful  antiseptic  precautions. 
Where  this  precaution  has  been  taken,  and  where  the  original  chancroid 
was  no  longer  a  source  of  infection,  I  have  never  seen  any  bubo  that 
did  not  heal  promptly  under  ordinary  antiseptic  dressings.  If  the 
bubo  after  it  is  opened  becomes  converted  into  a  chancroidal  ulcer, 
as  indicated  above,  it  must  itself  be  treated  as  the  original  chancroid; 
or  the  ulcer  may  be  excised  and  the  resulting  wound  cauterized. 

GONORRHEA. 

Gonorrhea  is  a  local  infection  of  mucous  membranes  caused  by  gono- 
coccus  (Xeisser,  1S79;  Bumm,  18S7).  This  is  a  diplococcus  which  is  a 
pure  parasite,  growing  best  at  body  temperature  and  soon  perishing 
when  discharged  from  the  body.  It  is  readily  killed  by  heat,  and  does 
not  survive  long  in  dried  secretions.  ^Mucous  membranes  with  cylin- 
drical-celled epithelium  are  much  more  easily  infected  by  the  gonococ- 
cus  than  are  those  covered  with  pavement  epithelium.  The  gonococcus 
is  founfl  in  the  purulent  exudate,  within  the  leukocytes,^  and  invades 
the  submucous  tissues  easily;   it  spreads  through  the  lymphatics, 

1  Some  pathologists  hold  that  unles.s  the  diplococci  in  question  are  intracellular 
they  cannot  be  certainly  cla.ssed  as  gonococci;  legal  proof  requires  the  growth  of 
a  pure  culture. 


1010  VENEREAL  DISEASES 

enters  the  blood  stream,  and  may  produce  a  general  infection  (a  mild 
form  of  pyemia).  In  the  latter  circumstances  secondary  localizations 
in  serous  membranes  are  frequent.  One  such  localization,  gonococcic 
arthritis,  has  been  studied  in  Chapter  XVI;  gonococcic  endocarditis  is 
treated  by  the  physician;  and  gonococcic  iritis  by  the  ophthalmologist. 
Whether  or  not  gonococcic  conjnyictivitis  (gonorrheal  ophthalmia) 
ever  occurs  by  infection  through  the  blood-stream  is  disputed;  cer- 
tainly in  most  cases  infection  occurs  by  mediate  contagion  through 
soiled  towels,  etc. 

Gonococcic  Urethritis. — Urethral  inflammation  due  to  infection 
by  the  gonococcus  is  the  commonest  venereal  disease.  In  the  female 
the  infection  localizes  itself  especially  in  the  vulvovaginal  canal,  not 
so  much  in  the  urethra.  In  man  the  infection,  acquired  in  sexual 
intercourse,  becomes  localized  in  the  anterior  urethra,  especially  the 
fossa  navicularis;  unless  there  is  phimosis,  causing  retention  of  secre- 
tions, the  glans  penis  and  prepuce  usually  escape  infection  owing 
to  the  character  of  their  epithelial  covering.  From  the  anterior 
urethra  the  inflammation  usually  spreads  throughout  the  entire  canal, 
and  is  especially  apt  to  remain  localized,  in  chronic  form,  in  the  deep 
urethra  and  prostate.  Throughout  the  urethra  the  submucous  tissues 
are  invaded,  and  inflammation  of  the  glands  of  Littre  is  common; 
these  may  be  converted  into  abscesses,  which  rupture  into  the  urethra 
or  rarely  externally.  Inflammation  of  Cowper's  glands  is  more  apt 
to  result  in  external  rupture,  and  is  the  chief  cause  of  periurethral 
abscess  fp.  1027)  and  periurethral  urinary  fistulse.  The  healing  of 
these  patches  of  inflammation  or  follicular  abscesses  may  result  in 
the  formation  of  urethral  strictures  fp.  1019). 

Symptoms  and  Clinical  Course. — 1.  In  Acute  Gonococcic  Urethritis, 
vulgarly  known  as  the  clap,  the  first  symptoms  usually  appear  on  the 
third  or  fourth  day  after  contagion,  and  consist  in  tingling  and  itching 
of  the  urinary  meatus.  On  inspection  the  lips  of  the  meatus  are  found 
swollen,  and  there  is  a  slight  glairy  discharge  which  causes  them  to 
adhere  between  the  acts  of  urination.  A  scalding  sensation  in  passing 
water  is  very  frequent.  One  or  two  days  later  a  profuse  purulent, 
sometimes  blood-stained  discharge  appears;  the  ardor  urincB  lessens; 
painful  erections  are  frequent;  and  edema  of  the  foreskin  may  occur 
with  phimosis  or  paraphimosis  (Fig.  973)  and  resulting  balano-posthitis. 
Later,  fluring  erection,  the  penis  may  be  bent  downward  or  laterally 
(chordee) ;  this  painful  symptom  is  due  to  the  inability  of  the  spongy 
portion  of  the  penis,  which  surrounds  the  inflamed  urethra,  to  become 
elongated  to  the  same  extent  as  the  cavernous  bodies.  Epididymitis 
(p.  1052)  is  another  frequent  complication.  In  almost  all  cases  of 
gonorrhea  the  inflammation  extends  within  a  week  or  ten  days  to  the 
posterior  urethra.  This  event  may  pass  unnoticed,  or  may  be  evi- 
denced by  increasing  frequency  of  micturition,  vesical  tenesmus,  and 
sometimes  by  temporary  lessening  of  the  discharge.  Then  as  these 
symptoms  abate,  the  discharge  may  again  increase.  Even  in  severe 
cases,  constitutional  symptoms  usually  are  absent. 


GONORRHEA  1011 

Acute  fionoc'occic  urethritis  tends  to  run  a  self-limited  course,  almost 
all  symj)t()ms  dis;ipj)earin<:;  witliiu  six  to  ten  weeks,  no  matter  what 
treatment  is  employed,  or  even  if  no  treatment  is  emj)loyed;  hut  i)roper 
treatment  usually  hastens  subsidence  of  symjjtoms.  In  almost  all 
cases,  however,  subsidence  of  acute  symptoms  does  not  indicate  that 
the  disease  is  cured,  but  merely  that  it  has  become  chronic  or  latent. 
The  tronococci  remain  localized  in  the  deep  urethral  crypts,  in  the 
prostatic  utricle,  prostate  gland,  or  seminal  vesicles,  and  after  any 
excess  in  eating  or  drinking,  after  excessive  coitus,  and  sometimes  from 
no  ascertainable  cause,  a  urethral  discharge  containing  gonococci  will 
appear,  may  cause  a  temporary  renewal  of  acute  symptoms,  and  is 
ca])able  of  conveying  contagion  to  another  individual. 

2.  Chronic  Gonococcic  Urethritis,  known  also  as  the  gleet,  is  a  very 
frequent  sequel  of  acute  posterior  urethritis.  The  symptoms  are 
insignificant,  the  most  constant  being  slight  mucous  or  purulent  dis- 
charge (])erha])s  only  a  drop  or  two)  from  the  meatus,  observed  w  hen 
the  patient  wakens  in  the  morning.  After  defecation,  or  during  sexual 
excitement,  a  similar  slight  discharge  may  occur.  If  a  sound  is  passed 
into  the  penile  urethra,  the  chronically  inflamed  urethral  glands  often 
may  be  detected  as  small  nodules,  by  running  the  finger  along  the  under 
surface  of  the  penis.  Sometimes  vesical  tenesmus  is  annoying  at 
intervals.  There  may  be  frequent  erections  and  nocturnal  pollutions, 
and  the  seminal  discharge  sometimes  is  blood-stained. 

Diagnosis. — The  diagnosis  of  acide  gonorrhea  usually  may  be  made 
clinically,  but  it  is  alwaj's  w^ell  to  stain  a  smear  of  the  discharge  and 
examine  it  for  gonococci.  If  the  anterior  urethra  only  is  involved, 
and  the  patient's  urine  is  collected  in  two  glasses,  the  second  portion 
will  be  clear,  as  the  urine  first  passed  will  have  washed  away  all  the 
secretions.  If,  however,  the  posterior  urethra  is  involved,  the  second 
glassful  of  urine  will  be  cloudy  or  will  contain  shreds  of  mucus,  since 
the  pressure  of  accumulated  secretions  pent  up  in  the  deep  urethra 
can  force  the  vesical  sphincter  and  allow  the  urethral  discharge  to  mix 
with  the  urine  in  the  bladder.  In  chronic  gonorrhea  it  is  indispensable 
to  examine  the  urethral  discharge  for  gonococci.  If  no  secretion  is 
readily  available,  the  prostate  and  seminal  vesicles  should  be  given 
gentle  massage,  as  indicated  at  p.  1(313,  to  force  their  contents  into 
the  urethra.  A  number  of  laboratory  examinations  may  be  necessary 
before  gonococci  can  be  found.  In  chronic  urethritis  the  second 
urine  constantly  contains  shreds. 

Treatment.^ — Certain  general  directions  should  be  given  a  patient 
suffering  from  gonorrhea.    He  should  be  warned  of  the  danger  of  con- 

^  The  prevention  of  venereal  disease  is  to  be  regarded  as  a  scientific  and  not 
simply  a  moral  problem.  It  is  self  evident  that  the  simplest  means  of  prevention 
(abstention  from  impure  coitus)  is  the  most  efficient,  but  cannot  always  be  enforced 
upon  patients.  In  t  he  case  of  enhsted  men  in  the  army  and  navy  it  has  been  found 
advisable  to  adopt  definite  rules  of  venereal  prophylaxis.  Holcomb  and  Gather 
(1912)  report  the  results  in  the  United  States  Navy,  where  the  following  rule  was 
enforced  after  every  exposure  to  venereal  disease:  (1)  Wash  the  penis  (head  and 
shank  and  under  frenum)  with  1  to  5000  bichloride  of  mercury  solution,  using  a 


1012  VENEREAL  DISEASES 

tagion,  especially  of  gonorrheal  ophthalmia ;  the  possibility  of  compli- 
cations, especially  epididymitis,  should  be  called  to  his  attention; 
and  he  should  be  instructed  as  to  precautions  concerning  diet,  rest, 
hygiene,  and  cleanliness.  He  should  drink  plenty  of  water,  and  should 
take  no  alcoholic  liquor  at  all,  unless  a  confirmed  drinker.  He  should 
wear  a  suspensory  bandage,  and  if  possible  during  the  acutely  inflam- 
matory stage  he  should  remain  in  bed  with  the  scrotum  elevated. 
The  discharge  should  not  be  kept  dammed  up  in  the  urethra  by 
dressings;  but  the  lips  of  the  meatus  should  be  greased  with  vaselin 
and  the  discharge  collected  in  loosely  applied  absorbent  cotton  which 
is  changed  frequently.  The  presence  of  phimosis  may  add  the  com- 
plication of  balano-posthitis,  and  a  dorsal  slit  of  the  foreskin  may  be 
advisable  to  secure  free  drainage,  especially  if  chancroids  are  thought 
to  coexist.    Paraphimosis  seldom  requires  treatment. 


Fig.  943. — Urethral  sjringe.      (Watson  and  Cunningham.) 

If  the  patient  is  seen  in  the  earliest  stages  of  the  disease,  before 
profuse  discharge  has  commenced,  it  may  be  possible  to  secure  prompt 
arrest  of  the  disease  by  what  is  called  abortive  ireatmeni.  This  consists 
in  the  use  of  antiseptic  injections  into  the  urethra,  the  usual  substances 
employed  being  protargol  (2  to  5  per  cent.)  or  argyrol  (5  to  10  per  cent.) ; 
silver  nitrate,  in  strength  varying  from  1  to  2000  up  to  4  per  cent.,  is 
also  used.  The  patient  should  urinate  before  taking  the  injection,  which 
is  administered  by  means  of  a  glass  urethral  syringe  with  blunt  nozzle 
(Fig.  943).  This  is  carefully  introduced  into  the  meatus,  and  the  lips 
of  the  meatus  are  closed  tightly  around  the  nozzle  by  the  fingers  of  the 
left  hand,  as  the  piston  of  the  syringe  is  pushed  home  with  the  right. 
From  2  to  5  c.c.  of  the  solution  is  injected  twice,  the  second  injection 
being  held  in  the  urethra  for  several  minutes.  These  injections  are 
to  be  used  three  or  four  times  daily,  except  in  the  case  of  the  very 
strong  silver  nitrate  solutions,  which  should  be  used  only  once  daily 
and  by  the  surgeon  himself,  one  or  two  injections  often  sufficing. 
In  many  cases  in  which  this  abortive  treatment  is  promptly  instituted, 
the  results  are  excellent;  though  the  urethral  discharge  may  be  tem- 
porarily increased,  it  soon  decreases  again,  becoming  glairy  and  per- 
haps blood-stained,  and  then  ceasing  entirely,  within  a  week  or  ten 

cotton  sponge.  (2)  Pass  the  urine;  and  take  urethral  injection  of  2  per  cent, 
protargol  solution  and  hold  it  in  the  urethra  until  60  has  been  counted.  (3)  Rub 
50  per  cent,  calomel  ointment  well  into  foreskin,  head,  and  shank  of  penis,  especially 
the  frenum.  They  found  that:  1385  exposures  treated  as  above  in  the  first  .eight 
hours,  gave  19  infections,  or  1.37  per  cent.;  731  exposures  treated  as  above  in  eight 
to  twelve  hours,  gave  25  infections,  or  3.4  per  cent.;  920  exposures  treated  as  above 
in  twelve  to  twenty-four  hours,  gave  46  infections,  or  5  per  cent. 


GONORRHEA  1013 

days.  In  other  cases  some  discharge  persists,  and  Further  treatment, 
as  in  the  elironie  stage,  nnist  he  instituted. 

It'  the  patient  is  seen  first  (hiring  the  inflammatory  stage  of  gonorrhea, 
it  is  not  advisahle  to  use  injections,  and  tiiey  should  be  discontinued 
if  previously  empk)yed.  In  this  stage  the  patient  should  remain  in 
bed  if  possible,  with  tlie  scrotum  well  elevated,  especially  avoiding 
sexual  excitement.  The  j)enis  should  be  immersed  in  hot  water 
several  times  daily,  as  the  heat  not  only  allays  the  inflammation  but 
is  germicidal  to  the  gonococci.  Internally,  capsules  containing  01. 
copaiba*  nivij,  and  Oleores  cubeb.  ITliij  may  be  given,  with  or  without 
methylene  blue  (gr.  ij)  and  sandalwood  oil  (ITlij).  Not  until  the  decline 
of  the  inflammation  should  injections  be  resumed,  and  as  the  discharge 
loses  its  purulent  character  and  becomes  mucoid  the  stronger  anti- 
septics may  be  abandoned  and  astringents  given  by  injection,  such 
as  zinc  or  copper  sulphate,  lead  acetate,  etc.  The  following  is  the 
formula  of  the  remedy  known  as  "brue:"  I^ — Plumbi  acetat.  gr.  xxx; 
Zinci  sulphat.  gr.  xvj;  Ext.  kramerise  fl.  f5iv;  Tinct.  opii  f'oiij;  Aquae 
destillat.  q.  s.  ad  f5  vj.  Internally  such  drugs  as  salol  or  urotropin  are 
indicated.  As  the  discharge  lessens  the  strength  of  the  astringent 
injections  should  be  gradually  diminished. 

The  treatment  of  chronic  gonococcic  urethritis  involves  discovery, 
if  possible,  of  the  habitat  of  the  remaining  germs,  and  their  destruction. 
For  this  purpose  examination  with  the  endoscope  often  is  advisable. 
Through  this  it  may  be  possible  to  detect  superficial  ulcerations  or 
erosions  of  the  urethra,  the  orifices  of  inflamed  urethral  glands,  etc.; 
or  by  the  use  of  bulbed  "sounds  the  presence  of  a  stricture  of  large 
calibre  (p.  1021)  maybe  determined;  or  with  the  cystoscope  the  pros- 
tatic utricle  and  orifices  of  the  ejaculatory  ducts  may  be  investigated. 
Chronic  prostatitis  and  seminovesiculitis  are  frequent  complications, 
and  it  may  be  impossible  to  discover  gonococci  in  a  chronic  urethral 
discharge  until  after  massage  of  these  structures,  as  described  below. 

For  lesions  of  the  anterior  urethra,  it  is  best  to  give  irrigations  three 
times  weekly.  The  solution  (silver  nitrate,  1  to  10,000;  potassium 
permanganate,  1  to  10,000;  protargol,  1  to  2000)  is  allowed  to  enter  the 
urethra  from  a  fountain  syringe,  by  the  force  of  gravity.  After  the 
urethra  has  been  well  cleansed  in  this  manner,  a  soft  catheter  is  passed 
into  the  bladder,  and  this  is  filled  with  the  solution;  the  catheter  is 
then  withdrawn,  and  the  patient  allowed  to  empty  his  bladder,  thus 
cleansing  the  entire  lower  urinary  tract  (Horwitz).  Strong  applica- 
tions are  then  made  to  the  erosions  through  the  endoscope.  If  there 
is  much  periurethral  infiltration,  the  passage  of  large-sized  sounds 
twice  weekly  is  of  benefit.  Stimulating  ointments  may  be  employed 
by  smearing  them  over  the  sound  and  then  gently  rubbing  the  corpus 
spongiosum  while  the  sound  is  in  place. 

If  lesions  persist  in  the  deep  urethra  it  is  well  to  make  instillations 
of  silver  nitrate  (0.5  per  cent.)  or  protargol  (0.25  to  2  per  cent.)  through 
a  deep  urethral  syringe  (Fig.  944)  after  massage  of  the  prostate,  which 
is  accomplished  by  introducing  the  index  finger  into  the  rectum,  and 


1014  VENEREAL  DISEASES 

gently  stroking  the  vesicles  and  each  lobe  of  the  prostate  downward 
toward  the  ejaculatory  ducts.  Too  violent  massage  may  set  up  a 
prostatitis  or  even  a  proctitis.  It  is  usual  to  have  the  patient  stand  in 
a  stooping  posture  for  massage  of  the  prostate,  the  surgeon  standing 
behind  him;  but  if  the  surgeon  has  a  little  practice  and  not  too  short 
a  finger,  it  is  more  convenient  to  have  the  patient  lying  supine.  Any 
urethral  discharge  which  follows  massage  of  the  prostate  should  be 
examined  for  gonococci,  and  if  these  are  found  persistently  absent 


Fig.  944. — Keyes'  deep  urethral  sjTinge.     (Watson  and  Cunningham.) 

at  a  number  of  examinations  made  at  intervals  after  stopping  all 
treatment,  the  urethritis  may  be  considered  cured.  Sometimes  pro- 
longed treatment  causes  a  non-gonococcic  urethritis,  and  cessation  of 
local  treatment  and  attention  to  the  patient's  general  health  may  be 
successful  in  stopping  a  discharge  which  seems  otherwise  incurable. 
Microscopical  examination  of  the  discharge  in  such  cases  may  show  the 
presence  of  staphylococci,  streptococci,  or  colon  bacilli.  The  use  of 
autogenous  vaccines  may  be  of  use  in  such  cases,  as  well  as  in  chronic 
gonococcic  urethritis. 


CHATTEU   XXVII. 
SUUGERY  OF  THE  URETHRA  AND  PROSTATE. 


SURGERY  OF  THE  URETHRA. 

Bougies  and  Sounds  (Fig.  945)  may  be  regarded  as  solid  catheters 
(p.  [)i)S).  They  are  used  in  the  diagnosis  and  treatment  of  urethral 
strictures.  The  bougie  (so-called  because  originally  made  of  wax)  is 
flexible;  the  old  French  bougie  a  houle  is  inferior  to  the  modern  bul- 
bous-tipped French  bougies  made  of  webbing,  like  English  catheters. 
The  best  have  a  core  of  lead  which  gives  them  sufficient  weight  to 
facilitate  their  introduction.  Filiform  bougies  are  made  of  whalebone, 
and  should  be  perfectly  flexible  and  highly  polished.  Sounds  are 
metallic  instruments;  they  should  be  highly  polished  or  nickel-plated, 
of  sufficient  weight  to  sink  into  the  urethra  easily,  and  provided  with 


Fig.  945. — Urethral  sounds  and  bougies:  1.  Steel  sound.  2.  Bulbed  sound.  3. 
Bougie  a  boule.  4.  Olive  tipped  bougie,  made  of  webbing,  with  a  leaden  core.  5,  6,  7, 
Filiform  bougies,  made  of  whalebone. 

a  suitable  handle,  to  prevent  slipping.  They  are  introduced  in  the 
same  way  as  metal  catheters'  (Figs.  946  and  947).  Bulbed  sounds  cor- 
respond to  the  bougies  a  boule;  they  are  of  use  in  determining  the 
extent  and  site  of  a  stricture,  by  the  sensation  they  impart  to  the 
examiner's  hand  when  the  bulb  catches  on  the  anterior  or  posterior 
face  of  the  stricture. 

Retention  of  Urine. — Retention  of  urine  is  a  condition  which  occurs 
so  often  in  affections  of  the  urethra,  that  it  is  convenient  to  enumerate 
its  varieties  at  the  outset.  First  there  is  (1)  Acute  Complete  Retention: 
the  patient,  previously  able  to  evacuate  his  urine  wholly  or  in  part, 
suddenly  becomes  unable  to  do  so;  all  the  urine  is  retained,  and  the 


1016 


SURGERY  OF   THE   URETHRA   AND  PROSTATE 


Fig.  946. — Passing  a  sound  from  the  pa- 
tient's right  side.  Observe  how  the  sound  is 
held  in  the  fingers,  and  note  that  no  force  can 
be  used.    Episcopal  Hospital. 


condition  is  aaite.  (2)  Acute  Incomplete  Retention  occurs  when  the 
patient  is  just  able  to  void  a  few  drops,  with  much  effort;  the  condi- 
tion is  acute,  but  a  little  of  the  urine  is  passed.  (3)  Chronic  Complete 
Retention,  where  the  patient  depends  absolutely  upon  the  catheter 

for  emptying  his  })ladder, 
though  the  condition  is 
chronic,  and  the  catheter 
has  been  required  for  months 
or  years.  (4)  Chronic  Incom- 
plete Retention  icithoiit  disten- 
iion  of  the  bladder,  where  a 
certain  portion  of  urine  is 
constantly  retained,  but  where 
the  major  portion  is  evacuated 
voluntarily;  a  chronic  condi- 
tion, where,  without  the  blad- 
der being  over-filled,  residual 
urine  exists.  Finally  there  is 
(a)  Chronic  Incomplete  Reten- 
tion ^cith  distention  of  the  blad- 
der, where  so  much  of  the 
urine  is  retained  that  the  bladder  has  reached  the  limit  of  its  capacity, 
and  overflow  from  retention  results. 

We  may  tabulate  these  conditions  as  follows: 
I.  Acute  Retention. 

1.  Acute  Complete  Re- 
tention. 

2.  Acute  Incomplete  Re- 
tention. 

II.  Chronic  Retention. 

3.  Chronic  Complete  Re- 
tention. 

4.  Chronic  Incomplete 
Retention  without  dis- 
tention of  the  bladder. 

5.  Chronic  Incomplete 
Retenfion  with  disten- 
tion of  the  bladder. 

The  first  of  these  conditions 
occurs  oftenest  as  a  complica- 
tion of  stricture  of  the  urethra; 

the  second  in  cases  of  urethritis;  the  third,  fourth,  and  fifth  are  seldom 
seen  except  in  cases  of  enlargement  of  the  prostate. 

Foreign  Bodies. — Foreign  bodies  may  enter  the  urethra  from  the 
bladder  (calculi,  etc.)  or  from  without.  The  end  of  a  catheter  or 
filiform  bougie  occasionally  breaks  oft';  and  sometimes  a  patient  passes 
implements  into  the  urethra  to  relieve  some  fancied  obstruction,  and 
the  instrument  breaks  oft'  or  escapes  from  his  fingers.    There  is  danger 


Fig.  947. — The  urethral  sound  fully  intro- 
duced. Note  the  angle  it  makes  with  the 
horizon.     Episcopal  Hospital. 


RUPTURE  OF  THE   URETHRA  1017 

of  such  hodies  esciiping  into  the  hladdcr,  and  they  may  seriously 
traumatize  the  uretiira.  It  is  very  important  not  to  introduce  a 
sound  incautiously  for  tlie  purposes  of  diaj^nosis,  since  it  is  apt  to 
push  the  foreign  body  up  into  the  bladder,  or  to  embed  it  in  the  ure- 
thral wall.  It  is  better  to  make  the  diaji^nosis  by  means  of  the  a'-ray, 
whenever  this  is  available.  It  is  rare  for  foreign  bodies  to  produce 
complete  urinary  obstruction,  but  they  scarcely  ever  can  be  washed 
out  by  the  stream  of  urine.  Fortunately  sufficient  time  usually  is 
availabkvto  send  the  patient  to  a  well  ecpiipped  hospital.  There  it 
may  be  possible  to  extract  the  foreign  body  by  the  aid  of  the  endo- 
scope, or  even  l)y  alligator  forceps  (Fig.  94S)  introduced  closed  and 
opened  when  they  are  felt  to  come  into  contact  with  the  foreign  body. 
Occasionally  a  pencil  or  similar  article  may  be  worked  out  step  by 
step  by  forcing  the  penis  down  over  it  as  it  is  fixed  with  the  fingers 
through  the  perineum  or  the  penile  urethra.  A  hat  pin,  introduced 
into  the  urethra  head  first  may  be  extracted  by  protruding  its  point 
through  the  body  of  the  penis,  re- 
versing it,  and  pushing  it  out  head 
first.  If  all  other  methods  fail  ex- 
ternal urethrotomy  (p.  1022)  should 
be  done;  an  incision  in  the  penile 
urethra  should  be  sutured,  but  one  fig.  948.— Urethral  forceps. 

in  the    perineum    may  be    left    to 

heal  by  granulation.  If  the  foreign  body  has  escaped  into  the  blad- 
der it  may  be  removed  by  suprapubic  cystotomy,  if  extraction  with 
the  operating  cj'stoscope  is  impossible. 

Traumatic  Rupture  of  the  Urethra  usually  is  the  result  of  direct 
injury  (falls,  kicks,  etc.)  to  the  perineum;  occasionally  it  occurs  as 
a  complication  of  fracture  of  the  pelvis.  The  lesion  almost  always 
is  in  the  subpubic  urethra,  at  the  bulbo-membranous  juncture.  The 
diagnosis  depends  on  the  history  of  traumatism,  and  the  passage  of 
bloody  urine  or  on  the  symptom  of  "bloody  anuria"  (p.  971).  In 
most  cases  urinary  extravasation  occurs  after  twenty-four  hours.  If 
the  rupture  occurs  anterior  to  the  superficial  layer  of  the  triangular 
ligament,  the  urine  passes  first  into  the  perineum  and  being  confined 
by  Colles's  fascia  rapidly  forces  its  way  through  the  cellular  tissues  of 
the  scrotum  on  to  the  abdominal  walls,  through  the  abdomino-scrotal 
opening.  If  rupture  occurs  above  the  triangular  ligament,  the  symp- 
toms resemble  those  of  extraperitoneal  rupture  of  the  bladder,  but 
the  history  of  injury  to  the  perineum,  with  resulting  ecchymosis, 
etc.,  points  to  the  urethra  as  the  seat  of  the  lesion.  If  urinary  extra- 
vasation is  unrelieved,  extensive  sloughing  will  occur,  especially  if 
the  urine  was  previously  unhealthy ;  constitutional  symptoms  of  sepsis 
are  frequent,  and  death  may  ensue  from  this  cause. 

Treatment. — Treatment  consists  first  in  guarded  attempts  to  enter 
the  bladder  with  a  soft  catheter.  If  this  succeeds,  as  it  may  very 
soon  after  the  injury,  before  urinary  extravasation  has  occurred, 
the  catheter  should  be  left  in  the  bladder  for  four  or  fi-\'e  days,  while 


1018  SURGERY  OF  THE   URETHRA   AXD  PROSTATE 

urinary  antiseptics  are  administered.  If  extravasation  of  urine  is 
already  present  when  the  patient  is  seen,  the  urethra  should  be  opened, 
immediately,  in  the  perineum,  with  the  aid  of  a  sound  passed  down 
to  the  site  of  rupture.  Numerous  incisions  in  the  perineum,  scrotum, 
and  skin  of  the  abdominal  wall  may  be  necessary  to  secure  free  drain- 
age and  avert  threatening  sepsis.  Usually  there  need  be  no  fear  that 
the  patient  will  be  unable  to  empty  the  bladder  through  the  wound, 
and  it  is  not  necessary  to  drain  the  bladder  by  a  catheter;  but  if  the 
vesical  end  of  the  urethra  is  readily  found  this  may  be  done.  In  a 
case  of  rupture  of  the  urethra  above  the  triangular  ligament  I  success- 
fully employed  Demarquay's  operation  I'lSoSjrthis  consists  in  dis- 
secting down  to  the  site  of  rupture  through  a  curved  incision  con- 
vexity forward)  as  in  the  modem  operation  of  perineal  pjrostatectomy 
(p.  1040).  Some  surgeons  advocate  suture  of  the  ruptured  urethra ; 
but  in  all  the  cases  which  have  come  under  my  care,  the  local  condi- 
tion precluded  such  a  step.  When  the  perineal  wound  begins  to 
granulate,  it  is  usually  possible  to  pass  a  sound  through  the  penis 
into  the  bladder,  and  if  this  is  done  once  or  t^ice  weekly,  the  perineal 
wound  soon  closes.  The  danger  of  subsequent  stricture  formation, 
however,  is  very  great.  Traumatic  stricture  forms  rapidly  after  injury 
and  the  palliative  methods  and  e\  en  tlie  usual  operations  employed 
for  stricture  the  result  of  gonorrhea  seldom  prevent  recurrence,  owing 
to  the  dense  nature  of  the  scar  and  its  extent.  Unless  the  patient 
can  have  bougies  passed  at  least  once  monthly  for  many  years  ('perhaps 
throughout  life,),  it  is  better  to  excise  the  strictured  area  and  to  unite 
the  healthy  urethra  above  and  below  by  sutures,  over  a  catheter 
which  is  left  in  place  for  several  days  or  until  the  urethral  wound  is 
healed.  I  employed  this  method  wdth  most  happy  results  in  the  case 
of  the  boy  shown  in  Fig.  953.  Though  only  ten  years  old,  his 
urethra  easily  admitted  a  Xo.  IS  Fr.  sound  one  year  after  operation. 

Non-gonococcic  Urethritis  occasionally  occurs,  the  chief  causes 
being  instrumentation,  stricture,  ingestion  of  irritating  drugs,  excessive 
coitus,  or  masturbation,  etc.  If  the  condition  is  chronic  it  probably  is 
kept  up  by  a  stricture  or  a  focus  of  inflammation  in  the  prostatic 
iu"ethra  or  its  adnexa.  The  acute  form  usually  subsides  so  soon  as 
the  cause  is  removed.  The  treatment  of  the  chronic  form  is  the  same 
as  for  chronic  gonococcic  urethritis  fp.  1013). 

Prolapse  of  the  Urethra  is  rare.  It  occurs  oftenest  in  female 
children,  from  straining  efforts  (coughing,  defecation,  micturition). 
The  protrusion,  which  seldom  involves  more  than  the  mucosa,  may 
be  excised,  and  bleeding  checked  by  pressure,  cauterization,  or 
suture. 

Stricture  of  the  Urethra. — Several  varieties  of  urethral  -tricture  are 
recognized: 

I.  Inorganic  Strictures. — 1.  Inflammatory  Stricture,  or  obstruction  of 
the  urethra  from  acute  inflammation.  This  is  the  form  which  occa- 
sionally occurs  during  the  acute  stage  of  gonorrhea,  resulting  in  acute 
complete  retention  of  urine;  it  also  occurs  from  pressure  outside  the 


STRICTURE  OF  THE  URETHRA  1019 

urethra,  from  an  iiiHamed  prostate,  periuretliral  abscess,  etc.  It  is  to 
be  treated  by  j)alliativc  measures  sucli  as  inrlicated  under  spasmodic 
stricture,  or  incision  and  draina^^e  tlir()Uj,di  the  j)crincum  of  i)rostatic 
or  periurethral  abscesses.  IntrcKluction  of  a  catheter  shoukl  be 
avoided  whenever  possible;  if  retention  persists,  the  bladder  may  be 
aspirated  above  the  pubis.  (2)  Spa.s-niixlic  Stricture:  This  is  no 
stricture  at  all,  merely  a  si)asm  of  the  urethra,  tliough  it  occurs  most 
often  in  ])atients  with  organic  stricture.  It  occurs  also  as  the  result 
of  psychic  influence  (as  where  an  individual  cannot  urinate  in  the 
presence  of  others),  in  cases  of  inflamed  hemorrhoids  or  of  semino- 
vesiculitis,  after  surgical  operations,  in  the  course  of  the  infectious 
fevers,  etc.  Spasm  usually  occurs  in  the  membranous  urethra,  from 
the  contraction  of  the  deep  transversus  perinei  muscle.  //  retention 
is  complete,  and  of  eight  hours  or  more  duration,  a  catheter  should 
be  used;  if  incomplete  or  recent  palliative  measures  may  be  tried  for 
some  hours.  Among  the  most  effective  is  a  liot  bath,  the  patient 
attempting  to  urinate  in  the  bath;  enemas  of  laudanum,  followed  by 
a  pmge,  may  also  be  used.  Recurrence  of  spasm  must  be  prevented 
by  attending  to  the  condition  of  the  urine,  and  relieving  any  local 
cause,  especially  organic  stricture 

II.  Organic  Strictures. — (1)  Traumatic  Stricture  has  been  described 
at  p.  1018.  (2j  Congenital  Stricture  is  less  rare  than  usually  supposed, 
but  may  produce  no  symptoms  until  the  age  of  puberty  or  later. 
(3)  Stricture  from  Cicatrices  following  Urethritis,  almost  always  the 
result  of  gonorrhea,  is  the  type  most  often  seen,  and  what  is  said 
in  the  following  pages  refers  especially  to  it. 

Strictures  result  from  submucous  round-celled  infiltration,  which 
passes  through  the  usual  stages  of  organization,  cicatrization,  and 
contraction.  As  gonococcic  urethritis  is  most  frequent  al)out  the  age 
of  twenty  years,  strictures  are  seen  oftenest  in  early  adult  life;  they 
seldom  present  symptoms  for  the  first  time  after  forty  years  of  age. 
They  may  occur  in  any  portion  of  the  urethra,  but  are  most  frequent 
in  the  subpubic  portion,  especially  the  bulbous  urethra,  but  are  not 
rare  in  the  penile  urethra.  Stricture  of  the  membranous  and  prostatic 
uretlu"a  is  rare.  Strictures  usually  are  multiple  (Fig.  949),  and  may  be 
of  various  forms  (Fig.  950).  Their  calibre  varies  from  that  which  is 
impassable  to  the  finest  instrument,  up  to  those  which  barely  con- 
strict the  urethral  lumen  and  which  may  be  detected  only  by  the 
aid  of  a  bulbed  sound.  The  orifice  of  the  stricture  may  be  central 
or  eccentric. 

Symptoms  and  Clinical  Course  of  Stricture. — ^The  early  symptoms  of 
stricture  usually  are  insignificant,  but  occasionally  acute  retention 
of  urine  is  the  first  indication  of  trouble.  In  most  cases  the  patient 
complains  first  of  slight  gleety  discharge,  with  pain  in  the  deep  urethra 
during  and  following  urination;  he  finds  the  calls  to  lu-inate  more 
frequent,  the  stream  is  diminished  in  size,  and  a  longer  time  is  required 
to  empty  the  bladder.  Attacks  of  acute  retention  are  frequent,  from 
inflammatory  changes  or  plugging  of  the  stricture  by  a  pellet  of  mucus 


1020 


SURGERY  OF   THE   URETHRA   AXD  PROSTATE 


or  pus.  Retention  with  overflow  is  another  frequent  sequel.  From 
straining  in  micturition,  hemorrhoids  or  prolapse  of  the  rectum  may 
develop.  The  urethra  immediately  behind  the  stricture  becomes 
dilated,  and  as  backward  pressure  continues,  changes  occur  in  the 
bladder.  The  bladder  at  first  may  hypertrophy,  but  in  most  cases 
a  condition  of  atrophy  (fibroid  degen- 
eration) sets  in  eventually,  so  that  the 
bladder  loses  its  power  of  contraction. 
This  is  predisposed  to  by  cystitis, 
which  is  prone  to  develop  (owing 
to  stagnation  of  urine)  as  the  result 
of  instrumentation  or  as  a  descend- 
ing infection  from  the  kidney.  Pres- 
sure diverticida  may  form  in  the 
bladder,  and  eventually  dilatation  of 
the  ureters  and  renal  pelves  may  oc- 
cur, with  hydronephrosis,  pyonephro- 


V 


Linear 
Stricture. 


Annular 
Stricture. 


Fig.  949. — Strictures  of  the  urethra.  A 
probe  has  been  passed  through  a  false  passage 
in  the  bulbous  urethra.     (After  Albarran.) 


Tortuous 
Stricture. 


Fig.  950.^ — Diagram  of  different 
forms  of  stricture.  (Watson  and 
Cunningham. J 


sis,  or  surgical  kidneys.  Other  complications  and  sequels  are  frequent. 
The  most  important  'Pretention  of  Urine,  Urethral  Fever.  Extravasa- 
tion of  Urine,  Periuretlu-al  Abscess,  Urinary  Fi^tuhe,'  are  discussed 
in  the  following  pages. 

Diagnosis   of   Stricture. — While  the   existence  of   stricture   usually 
may  be  surmised  fmm  it-  -yniptoms  enumerated  above,  or  from  its 


TREATMENT  OF  STRICT U RE  OF   THE   URETHRA         1021 

various  s('(|1H'1s,  xcrificatinii  of  tlic  diuffiiosis  (k'pciids  on  iiistriiinental 
cxaniiiiation  of  tlic  urethra.  TUv  calibre  of  tlir  uornial  urctlira  corres- 
pouds  with  the  circuniference  of  the  penis:  a  circumference  of  'A  inches 
implies  a  urethral  calibre  of  oO  mm.  of  the  French  scale  (p.  959); 
3 J  inches  corresponds  to  82  Fr.;  85  inches  corresponds  to  34  Vr.,  etc. 
The  (tirragc  iircflini  admits  a  Xo.  '.V2  Fr.  sound,  but  the  njeatus  usually 
is  smaller  than  the  urethra  within.  Strictures  of  large  calibre  are  best 
detected  by  passage  of  a  bulbed  sound.  Such  strictures  require  treat- 
ment only  if  productive  of  definite  symptoms.  Strictures  of  medium 
or  small  calibre  will  cause  the  arrest  of  an  ordinary  steel  sound  of 
average  size.  It  is  always  well  to  commence  the  examination  by 
passing  a  full  sized  sound,  and  then  to  try  smaller  sizes  in  turn  until 
one  is  passed  into  the  bladder.  It  is  not  safe  to  use  an  inflexible 
sound  smaller  than  Xo.  10  Fr.,  for  fear  of  making  a  false  passage. 

Treatment  of  Stricture. — There  are  two  main  classes  of  strictures, 
the  treatment  of  which  it  is  convenient  to  consider  separately:  these 
are  permeable  and  imyermeahle  strictures.  By  the  former  is  meant 
a  stricture  through  which  an  instrument  can  be  passed;  and  by  the 
latter  one  through  which  no  instrument  of  any  size  or  form  whatever 
can  be  passed.  This  distinction  is  relative,  since  a  stricture  which  a 
surgeon  finds  impermeable  on  one  occasion  may  not  be  so  on  another 
occasion  nor  for  another  surgeon. 

1.  Treatment  of  Permeable  Stricture. — 1.  The  best  treatment 
is  that  by  gradual  dilatation.  A  sound  just  large  enough  to  be  grasped 
by  the  stricture  is  passed  about  twice  weekly,  and  the  size  of  the  sounds 
passed  is  very  gradually  increased.  Thus  if  X"o.  14  Fr.  has  been  passed 
with  a  little  difficulty  on  the  first  occasion,  it  is  well  to  begin  the  second 
seance  with  Xo.  12  Yt.,  and  not  to  push  dilatation  beyond  X"o.  16  Fr. 
At  the  third  sitting  Nos.  14,  16,  and  18  Fr.,  probably  can  be  passed. 
It  is  then  desirable  in  the  average  case  to  continue  dilatation  until 
a  number  on  the  scale  is  reached  which  is  two  or  three  points  higher 
than  that  which  is  considered  normal  for  that  patient.  But  in  the 
case  of  multiple  or  fibrous  strictures,  or  in  a  patient  who  is  old  or 
feeble,  or  prone  to  urinary  fever  or  other  complication,  it  is  best  to 
be  satisfied  with  keeping  a  canal  patulous  for  Xo.  22  or  24  Fr.  If 
over-dilatation  can  be  secured  gradually,  and  if  it  can  be  maintained 
for  several  months,  it  is  probable  that  no  further  trouble  will  be  experi- 
enced. Absorption  of  the  cicatricial  tissue  will  have  occurred,  and 
unless  a  new  stricture  forms  the  patient  may  consider  himself  cured. 
In  cases  where  it  is  impossible  to  push  the  dilatation  up  to  normal 
and  beyond,  it  is  necessary  for  the  patient  to  have  a  sound  passed  once 
monthly  for  the  rest  of  his  life.  X'eglect  of  this  precaution  wall  allow 
the  stricture  to  recontract,  and  relief  of  the  patient  will  then  be  more 
difficult. 

2.  Treatment  by  rapid  dilatation  or  rupture  of  the  stricture  is,  I 
believe,  best  adapted  to  strictures  of  large  calibre,  such  as  sometimes 
cause  persistence  of  a  chronic  urethritis;  though  even  in  these  cases 
gradual  dilatation  often  is  sufficient.     Rupture  is  accomplished  by 


1022 


SURGERY  OF  THE   URETHRA  AXD  PROSTATE 


various  forms   of  instruments   which  are  first  passed  through   the 
strictures  and  then  expanded  by  some  mechanical  device  (Fig.  951). 


Fir,.  951. — Kollnian's  urethral  dilator,      i  Watson  and  Cunningham.) 

3.  Incision  of  the  Stricture  (Urethrotomy)  is  the  best  treatment  for 
strictures  too  dense  and  fibrous  to  be  treated  successfully  by  gradual 
dilatation;  or  for  those  which  tend  persistently  to  recur,  even  after 
a  long  course  of  such  treatment.  But  it  should  ne\'er  be  forgotten 
that  it  may  be  more  judicious  to  persist  in  conservative  treatment 
in  the  old  and  feeble,  even  if  it  be  not  curative,  than  to  resort  e\en 
to  a  trivial  operation  which  may  suddenly  snuff  out  life. 


Fig.  952. — 1.  Ci\-iale's  urethrotome;  a  model  which  will  cut  the  stricture  from  behind 
forward,  or  from  before  backtcard.  2.  Sxtne's  grooved  staff  for  external  perineal  urethrot- 
omy.   3.  Tunnelled  catheter,  threaded  over  a  filiform  bougie. 

(a)  Internal  Urethrotomy  (Amussat,  1824)  is  especially  applicable  to 
strictures  of  the  penile  lu-ethra:  it  is  accomplished  by  introducing 
an  instrument  through  the  stricture  and  then  withdrawing  from  the 
instrument  a  concealed  blade  (Fig.  952,  1),  which  cuts  the  stricture 
on  the  roof  of  the  canal  from  behind  forward  (Civiale's  urethrotome, 
1849),  or  from  before  backward  (Maisonneuve's  urethrotome,  1855). 
The  operation  may  be  done  Under  local  anesthesia  (10  per  cent, 
eucain),  but  a  general  anesthetic  is  preferable.  After  either  of  these 
operations  it  is  best  to  retain  an  inlying  catheter  for  tliree  or  four 
days,  the  penis  being  bandaged  to  it  if  there  is  much  hemorrhage 
(which  is  unusual);  and  after  the  catheter  is  removed,  dilatation 
must  be  maintained  by  passage  of  sounds  for  several  weeks,  or  longer 
if  a  tendency  to  recontraction  is  evident. 

(6)  External  Urethrotomy. — This  operation  is  safer  than  internal 
lu-etlirotomy  for  strictiu-es  in  the  deep  urethra.  It  was  popularized 
by  S>Tne  in  1843,  and  is  commonly  known  a?  External  Perineal  Ure- 
throtomy with  a  Guide,  or  Syme's  operation:  A  guide  is  passed  through 
the  stricture  from  the  meatus,  and  the  bulbo-membranous  m-ethra  is 


TREATMENT  OF  IMPERMEABLE  STRICTURE  OF  URETHRA   1023 

then  ()j)eiiecl  from  tlic  i)orincuiii  upon  the  j^iiido  heliiiid  tiie  stricture, 
and  the  stricture  is  divided  from  behind  forward.  Syme  used  a  guide 
jmnidcd  witli  a  f^roove  upon  its  convexity  and  a  shoulder  which 
resteil  against  the  face  of  the  stricture  (Fig.  052,  2).  After  division 
the  stricture  should  be  fully  dilated  by  passage  of  steel  sounds  and  the 
bladder  drained  by  a  perineal  tube  for  several  days,  when  the  passage 
of  sounds  may  be  commenced,  and  the  perineal  wound  allowed  to 
heal  by  granulation. 

II.  Treatment  of  Impermeable  Stricture. — Very  few  strictures 
are  really  impermeable;  indeed,  it  has  been  asserted  by  several  eminent 
authorities  that  any  stricture  which  would  permit  urine  to  escape  from 
above  would  also  admit  an  instrument  from  below.  But  as  their 
experience  increased  they  were  forced  to  acknowledge  that  they 
themselves  had  encountered  strictures  which  remained  impermeable 
to  their  best  efforts.  If  the  patient  is  able  to  pass  his  urine,  there 
is  plenty  of  time  available  for  attempts  to  render  the  stricture 
permeable.  Hence  it  is  convenient  to  discuss  the  treatment  of 
impermeable  stricture  according  as  it  is  not  or  is  accompanied  by 
retention  of  urine. 

1.  Impermeahh  Stridnre  uithoni  Retention  of  Urine. — The  first 
efforts  of  the  surgeon  should  be  devoted  to  rendering  the  stricture 
permeable.  It  is  not  safe  to  let  a  patient  with  impermeable  stricture 
continue  as  he  is;  the  risks  of  retention,  urinary  extravasation,  etc., 
are  too  imminent.  After  trying  the  usual  steel  sounds,  and  finding  it 
impossible  to  pass  the  stricture  with  any,  down  to  No.  10  Fr.  (no 
smaller  inflexible  instrument  is  safe)  the  surgeon  should  next  try  fine 
flexible  bougies  (those  filled  with  a  leaden  core  are  best)  which  on  account 
of  their  very  flexibility  may  be  enabled  to  pass  through  a  tortuous 
stricture  which  is  absolutely  impermeable  to  a  rigid  instrument.^  If 
such  an  instrument  cannot  be  passed  (even  a  No.  1  Fr.  may  be  used 
without  fear  of  damaging  the  urethra),  //ifor?/i  whalebone  bougies  should 
be  employed.  These  should  be  sterilized  in  the  same  way  as  the  flexible 
bougies  and  catheters,  in  a  cold  5  per  cent,  formalin  solution  (p. 
959).  The  filiform  bougie  is  passed  down  to  the  face  of  the  stricture, 
where  it  may  be  arrested,  or  may  enter  a  false  passage  produced  by 
previous  instrumentation.  In  any  event  it  should  be  left  in  place, 
and  other  filiforms  should  be  passed  down  beside  it,  until  all  the  false 
passages  are  filled  and  the  face  of  the  stricture  is  covered  by  the  points 
of  the  bougies.  Then  as  the  last  filiform  is  introduced  it  may  slide 
at  once  through  the  stricture  and  into  the  bladder,  the  orifice  of  the 
stricture  being  the  only  point  unoccupied.^  Usually  not  more  than 
six  filiforms  are  introduced  at  once;  by  withdrawing  each  in  turn 
about  an  inch,  and  again  passing  it  down  against  the  face  of  the 

1  As  noted  at  p.  9.59,  passage  of  a  bougie  usually  is  easier  after  distending  the 
urethra  with  the  lubricant  by  means  of  a  sjTinge. 

-  If  an  endoscope  is  available,  it  may  be  possible  to  pass  a  filiform  through  the 
stricture  under  control  of  direct  vision. 


1024  SURGERY  OF  THE   URETHRA  AND  PROSTATE 

stricture  with  a  slight  twist,  the  surgeon  seeks  to  insinuate  one  of  the 
filiforms  into  the  orifice  of  the  stricture.  After  working  a  while  on  one 
side  of  the  patient's  bed,  it  sometimes  is  possible  to  accomplish  more 
by  passing  to  the  other  side  and  commencing  all  over  again,  as  the 
surgeon  "insensibly  works  the  filiforms  toward  himself  on  whichever 
side  he  stands  (J.  H.  Brinton).  If  a  filiform  finally  is  passed  through 
the  stricture,  //  should  be  allowed  to  remain  in  place.  This  applies  to 
any  instrument  which  has  been  passed  through  a  stricture  with  great 
difficulty.  The  continuous  dilatation  of  the  stricture  thus  produced 
will  render  easier  the  later  passage  of  a  larger  instrument.  When  a 
filiform  has  been  successfully  passed  through  a  stricture,  all  the  other 
filiforms  may  be  withdrawn;  and  a  tunnelled  catheter  (popularized 
by  Gouley  about  1873)  may  be  passed  over  the  filiform  into  the  bladder, 
and  retained  in  place  of  the  filiform;  this  acts  as  rapid  dilatation  or 
rupture  of  the  stricture.  Some  filiforms  are  provided  with  a  cap  and 
screw  thread  at  their  outer  ends,  so  that  a  larger  bougie  may  be  screwed 
on  and  pushed  through  the  stricture  as  the  filiform  is  pushed  into  the 
bladder  where  it  curls  up. 

In  a  case  a  stricture  remains  impermeable  in  spite  of  repeated  efforts 
to  pass  an  instrinnent,  resort  must  be  had  to  operation.  As  in  this 
operation  no  guide  can  be  passed  through  the  stricture  (as  is  a  pre- 
requisite for  performing  Syme's  operation),  it  is  known  as  External 
Perineal  Urethrotomy  without  a  Guide,  or  Perineal  Section,^  Here  a 
sound  is  passed  down  to  the  face  of  the  stricture,  and  the  urethra 
is  opened  on  this  as  a  guide,  in  front  of  the  stricture,  by  an  incision 
through  the  perineum.  The  margins  of  the  opened  urethra  are  then 
caught  in  guy  sutures  and  pulled  taut,  while  the  surgeon  endeavors  to 
pass  a  probe  or  filiform  bougie  through  the  stricture  whose  face  is 
thus  exposed  to  ^•iew  (Arnott,  1822).  By  forcing  a  few  drops  of  urine 
out  of  the  bladder,  the  orifice  of  the  stricture  may  become  visible. 
If  a  probe  can  be  passed  through  the  stricture,  the  operation  is  com- 
pleted as  in  Syme's  method,  by  dividing  the  stricture  on  the  guide. 
But  if  the  stricture  cannot  be  entered,  the  surgeon  proceeds  to  com- 
plete the  perineal  section,  dissecting  cautiously  backward,  strictly 
in  the  median  line,  until  he  has  divided  the  stricture  and  opened  the 
dilated  urethra  behind  it.  This  is  the  part  of  the  operation  which 
gives  it  the  name  of  perineal  section.^  It  is  an  operation  which  may 
prove  long  and  difficult,  but  with  a  good  light  and  steady  hand  it  is 
not  dangerous.  An  alternative  method  is  to  open  the  bladder  above 
the  pubis,  introduce  a  sound  into  the  vesical  orifice  of  the  urethra 

1  External  urethrotomy  scarcely  ever  is  necessary  for  strictures  of  the  penile 
urethra  because  these  very  rarely  are  impermeable;  but  it  may  be  employed  if 
requisite,  the  bladder  being  drained  by  an  inlying  catheter,  and  the  incision  in  the 
under  surface  of  the  penis  being  allowed  to  heal  by  granulation. 

^  Or  the  "old  operation,"  the  "London  operation"  (as  distinguished  from  the 
Edinburgh  operation,  or  Syme's). 

^  This  method,  according  to  Wiseman,  was  first  employed  in  1652  by  Molins; 
according  to  Guthrie  it  was  adopted  by  Sir  Astley  Cooper  in  1793.  The  operation 
was  systematized  by  Jameson,  of  Baltimore,  in  1824. 


TREATMENT  OF  IMPERMEABLE  STRICTURE  OF  URETHRA    102.') 

and  make  it  jirotriulo  in  tlu>  prriiirimi  holnnd  the  stricture;  tlie  urethra 
is  tluMi  opeuetl  on  this  fiuide,  throuuii  the  ])erineuni,  and  the  stricture 
is  cut  from  behind  forward.  This  method  of  "retrograde  catheteriza- 
tion," 1  regard  as  an  unnecessary  complication;  thouj^h  it  may  shorten 
the  operation,  it  docs  not  lessen  its  mortality  or  imjjrove  its  results, 
rather  the  reverse.  It  is  also  possible  to  open  the  urethra  at  the  apex 
of  the  i)rostate  (behind  the  stricture)  by  open  dissection  of  the  perineum 
(Guthrie,  1834;  Demarquay,  1858)  and  then  to  divide  the  stricture 
from  behind  forward ;  or  to  perform  Cock's  operation  (p.  ]  026)  and  com- 
plete it  as  did  John  Hunter  (1788)  and  (luthric  (1834)  by  division 
of  the  stricture  from  behind  forward.  IJut  the  best  operation  in 
impermeable  stricture  without  retention  of  urine,  is  the  perineal 
section,  as  systematized  by  Arnott  and  Jameson.  After  the  stricture 
has  been  cut  (by  whatever  method)  it  should  be  fully  dilated,  and  the 
bladder  drained  for  a  few  days  through  the  perineum. 


Fig.  '.1.3.'^. — Acute  complete  retention  of  urine  from  traumatic  stricture  of  urethra. 
Filiform  bougie  tied  in  the  urethra.  Age  nine  years,  injury  six  weeks  previously. 
Bladder  drained  iteslf  alongside  filiform  in  forty-eight  hours.  Treated  by  excision  of 
stricture.     (See  p.  1018.)     Episcopal  Hospital. 


2.  Impermeable  Stricture  with  Retention  of  Urine. — Here  there  is 
no  time  for  long  delay.  There  is  danger  of  urinary  extravasation, 
rupture  of  the  bladder,  etc.,  and  uremia  generally  impends  from 
renal  complications.  Not  more  than  thirty  minutes  should  be  spent 
in  attempts  to  pass  an  instrument  through  the  stricture;  if  a  filiform 
can  be  passed,  the  bladder  will  drain  itself  alongside  the  bougie  within 
tw^enty-four  to  forty-eight  hours  (Fig.  953)  and  immediate  operation 
is  unnecessary.  If  no  instrument  can  be  passed,  and  if  the  bladder 
is  much  distended,  temporary  relief  may  be  secured  by  tapping  it 
suprapubically;  and  occasionally  after  the  bladder  is  emptied  the 
stricture  becomes  permeable.  In  many  cases,  however,  the  bladder 
is  thickened  and  contracted  from  cystitis,  and  is  not  accessible  above 
the  pubis;  and  even  if  it  is  possible  to  aspirate  it  in  this  position,  more 
permanent  drainage  is  required  than  can  be  secured  in  this  way.  Hence 
relief  of  retention  is  best  accomplished  by  Tapping  the  Urethra  at  the 
65 


1026  SURGERY  OF  THE   URETHRA  AND  PROSTATE 

Apex  of  the  Prostate,  known  as  Cock's  operation.^  The  surgeon  intro- 
duces his  gloved  left  forefinger  into  the  rectum  and  places  it  upon  the 
apex  of  the  prostate.  Then  he  cuts  steadily  but  boldly  tlirough  the 
median  line  of  the  perineum  toward  his  finger  as  a  guide;  when  the 
knife  is  felt  to  approach  the  finger,  it  is  made  to  cut  obliquely,  opening 
the  dilated  urethra  at  the  apex  of  the  prostate,  behind  the  stricture. 
The  knife  is  then  withdrawn,  and  a  grooved  director  takes  its  place, 
the  left  forefinger  being  kept  in  the  rectum  to  serve  as  a  guide  until 
the  director  is  in  the  bladder.  The  finger  is  then  withdrawn  from  the 
rectum,  and  the  glove  removed.  The  left  hand  then  holds  the  grooved 
director  while  the  right  hand  passes  a  catheter  along  it  into  the  bladder, 
where  it  is  retained  for  several  days.  After  this  lapse  of  time  the  stric- 
ture usually  becomes  permeable.  The  main  object  of  the  operation, 
as  I  recommend  it,  is  to  relieve  acute  complete  urinary  retention  in  cases 
of  impermeable  stricture.  When  the  patient  has  been  put  out  of  jeop- 
ardy by  this  means,  other  suitable  measures  may  be  adopted  to  cure 
the  stricture.  In  many  cases  it  is  feasible  to  follow  Hunter's  and  Guth- 
rie's advice,  and  complete  the  primary  operation  by  division  of  the 
stricture  from  behind  forward.  In  other  cases  the  patient  is  in  such 
desperate  condition  when  first  seen  that  any  prolongation  of  the 
operation  is  injudicious.  Cock's  operation  has  often  been  described 
as  "dramatic  in  its  simplicity,"  and  it  is  its  extreme  simplicity  and 
the  rapidity  with  which  it  may  be  done  that  commend  it. 

Urethral  or  Urinary  Fever  is  a  form  of  sepsis  due  to  absorption  of 
bacteria  or  their  products  from  erosions  or  abrasions  of  the  urethra. 
In  some  patients  it  is  a  frequent  sequel  to  the  passage  of  a  sound  or 
catheter.  Symptoms  usually  do  not  appear  until  after  the  first  act 
of  urination,  subsequent  to  the  instrumentation.  In  most  cases  there 
is  only  a  feeling  of  chilliness,  with  anorexia  or  nausea,  and  some  eleva- 
tion of  temperature;  but  there  may  be  a  frank  chill.  In  rare  cases  true 
pyemic  symptoms  develop,  with  acute  monarticular  or  polyarticular 
effusion. 

Treatment. — Treatment  consists  in  the  internal  use  of  urinary  anti- 
septics for  some  time  before  urethral  instrumentation,  and  the  admin- 
istration of  a  full  dose  of  quinine  and  opium  as  soon  as  the  instrumen- 
tation is  completed.  In  case  of  severe  and  recurrent  attacks,  it  may 
be  desirable  to  drain  the  bladder  by  the  perineum,  until  the  urethra 
becomes  healtliier. 

Extravasation  of  Urine  has  been  referred  to  (p.  1017)  as  a  complica- 
tion of  rupture  of  the  urethra,  and  its  clinical  features  were  pointed 
out  in  that  place.  It  occurs  not  infrequently,  also,  in  cases  of  urethral 
stricture,  either  spontaneously,  or  as  the  result  of  false  passages  made 
by  careless  instrumentation.    That  false  passages  are  not  more  often 

^  This  is  a  variety  of  the  old  bouttonniere  operation,  revived  in  1856  by  Mr. 
Cock,  of  Guy's  Hospital,  as  a  treatment  for  impermeable  stricture  complicated  by 
urinary  fistula',  and  popularized  by  him  in  1866;  he  found  that  when  the  urine  was 
diverted  from  the  strictured  urethra  through  the  perineum,  the  fistulse  tended  to 
heal  spontaneously,  and  the  strictiu-e  usually  became  permeable. 


URINARY   FISTULA 


1027 


accompiiiiiod  l)v  urinary  extravasation  is  no  doubt  attributable  to  the 
fact  that  the  false  passages  have  their  orifices  directed  away  from  the 
bladder.  Extravasation  of  urine  occurs  sometimes  in  cases  where  no 
stricture  exists.  One  of  the  worst  cases  I  ever  saw  was  in  an  old  man 
of  seventy-three  years,  in  whom  no  urethral  obstruction  existed, 
and  in  whom  no  instruments  had  been  passed.  In  such  cases  it  is 
probable  that  perforation  of  the  urethra  occurs  as  the  result  of  unrec- 
ognized ulceration  or  the  rupture  of  a  peri-urethral  abscess.  Treat- 
ment, as  already  advised,  consists  in  perineal  urethrotomy,  and  free 
incisions  wherever  required  to  drain  the  extravasated  urine  or  remove 
sloughs. 

Peri-urethral  Abscess. — Peri-urethral  abscess  was  mentioned  at  p. 
1010  as  a  complication  of  gonococcic  urethritis.  Usually  one  or  both 
Cowper's  glands  are  involved,  and  a  tender  swelling  appears  to  one 
side  or  other  or  the  median  raj)he 
of  the  scrotum  at  its  junction  with 
the  perineum  (Fig.  954).  The 
condition  is  distinguished  from 
perianal  or  ischio-rectal  abscess 
by  its  less  acute  symptoms,  the 
history  of  urethral  disease,  and 
the  location  of  the  swelling  in 
the  perineum  rather  than  close 
to  the  anus. 

Treatment. — Treatment  consists 
in  incising  the  abscess  as  soon  as 
it  is  recognized,  in  the  endeavor 
to  prevent  its  rupture  into  the 
urethra,  as  this  latter  result 
almost  invariably  entails  the  sub- 
sequent formation  of  a  urinary 
fistula  in  the  perineum. 

Urinary  Fistulae. — Urinary  fistulse  usually  are  the  remote  result  of 
gonococcic  urethritis,  or  of  neglected  cases  of  extravasation  of  urine. 
Usually  the  fistula?  occur  in  the  perineum,  but  they  may  be  located 
in  the  scrotum,  in  the  penis  (floor  of  the  urethra),  in  the  adductor 
region  of  the  thighs,  or  in  the  buttocks.  In  almost  all  cases  the  com- 
munication with  the  urethra  is  on  the  vesical  side  of  a  stricture,  and 
proper  treatment  of  the  stricture  often  allows  the  fistulae  to  close. 
In  cases  where  no  stricture  exists,  however,  and  especially  where  the 
fistula  is  indurated  and  lined  with  mucous  membrane,  it  is  necessary 
to  do  a  formal  operation.  The  use  of  an  inlying  catheter,  and  cauteriza- 
tion of  the  fistulous  orifices  seldom  is  efficient.  The  urethra  should 
be  drained  behind  the  internal  orifices  of  the  fistulae  by  Cock's  or  by 
Syme's  technique,  according  as  there  is  or  is  not  an  impermeable 
stricture;  a  stricture  if  present  should  be  cut;  and  the  fistulous  tracts 
should  be  excised,  and  if  possible  closed  by  suture.  Perineal  drainage 
of  the  bladder  may  be  dipensed  with  after  a  week  and  full  sized  sounds 
should  be  passed  regularly  until  the  fistulae  have  healed. 


Fig.  954. — Peri-urethral  abscess,  on  the 
patient's  right.     Episfopal  Hospital; 


1()2S  SURGERY  OF  THE   URETHRA  AND  PROSTATE 


SURGERY   OF   THE   PROSTATE. 

Acute  Prostatitis  and  Abscess  of  the  Prostate. — Usually  this  is  a 
complication  of  posterior  urethritis  (gonococcic),  in^'ol^•ement  occur- 
ring by  direct  extension.  In  rare  cases  acute  prostatitis  may  result 
from  the  trauma  of  frequent  or  careless  instrumentation;  and  occa- 
sionally prostatic  abscess  occurs  as  a  metastatic  infection  in  the 
course  of  the  exanthemas,  typhoid  fever,  pneumonia,  etc. 

Symptoms. — The  symptoms  are  both  general  and  local.  General 
symptoms  (high  fever,  typhoid  state,  muttering  delirium)  if  severe, 
may  completely  mask  the  local  condition,  which  causes  intense 
burning  pain  in  the  rectum,  with  rectal  tenesmus  and  usually  reten- 
tion of  urine.  Examination  hy  a  finger  in  the  rectinn  (extremely 
painful)  detects  the  enlarged  tender  prostate.  One  or  both  lobes  may 
be  involved.  Only  if  an  abscess  is  very  near  the  surface  can  a  soft 
area  or  fluctuation  be  detected  by  rectal  palpation. 

Treatment. — Treatment  should  be  palliative  at  first.  A  brisk 
purge  should  be  given,  and  the  urine  rendered  alkaline  (Watson). 
Some  relief  may  be  secured  from  hot  rectal  irrigations  and  sitz  baths. 
Urinary  antiseptics  should  be  administered,  and  if  there  is  urinary 
retention  it  is  better  to  allow  a  soft  catheter  to  remain  constantly 
in  the  bladder  than  to  pass  it  frec|uently.  Operation  should  be  done 
after  twenty-four  or  forty-eight  hours  unless  relief  is  ol)tained  sooner; 
but  if  suppuration  is  suspected  operation  should  be  immediate.  Only 
if  the  abscess  is  manifestly  pointing  in  the  rectum  should  it  be  opened 
by  this  route;  in  such  cases  a  drainage  tube  should  be  passed  within 
the  sphincter  ani,  but  need  not  enter  the  prostate.  Whenever  possible 
it  is  better  to  expose  the  prostate  as  in  perineal  prostatectomy,  incis- 
ing one  or  both  lobes  and  draining  the  retroprostatic  space  by  tube  or 
gauze.  Even  if  pus  is  not  found,  relief  is  prompt  and  lasting.  During 
convalescence  it  is  well  to  resort  to  regular  prostatic  massage. 

Chronic  Prostatitis — Chronic  ])rostatitis  is  a  still  more  frequent 
complication  of  posterior  urethritis  than  is  the  acute  form  of  the  dis- 
ease. Usually  it  is  gonococcic  in  origin,  but  as  a  rule  secondary  infec- 
tion has  occurred,  and  only  the  pyogenic  cocci  or  the  colon  bacillus 
can  be  found.  It  is  insidious  in  onset,  and  patients  may  not  come 
under  treatment  until  many  years  after  the  causative  urethritis  has 
ceased  to  cause  annoj'ance. 

Symptoms. — The  main  local  symptom  is  a  chronic,  gleety,  urethral 
discharge.  General  neurasthenic  symptoms  are  frequent,  and  referred 
pain  may  be  felt  in  the  back,  thighs,  buttocks,  groins,  etc.  The  diag- 
nosis is  confirmed  by  examination  of  the  rather  abundant  secretion 
obtained  by  massage  of  the  prostate  (p.  1013).  Soon  after  the  primary 
lesion  gonococci  or  other  bacteria  are  found;  but  at  later  periods  the 
secretion  is  composed  almost  entirely  of  pus  cells,  and  even  these 
may  not  be  found  until  after  massage  has  been  employed  for  the  third 
or  fourth  time. 


ENLARGEMENT  OF   THK   PROSTATE 


1020 


Treatment.  The  \)vsX  trcatinciit  is  rcjiular  prostatic  luassuj^e, 
ahout  three  times  \veekl\ ,  followed  hy  urethral  and  vesical  irrigations, 
and  occasionally  hy  instillation  of  .">  per  cent,  silxcr  nitrate  or  the 
aj)plication  of  stinuilatini,^  ointments  to  the  deej)  urethra.  The  use 
of  the  kollman  urethral  dilator  ( l'\u.  !>.")l.  ]).  101*2)  may  also  prox'c  of 
\aluc. 

Enlargement  of  the  Prostate  This  often  is  spoken  of  as  hypertrophy 
of  the  i)rostate,  hut  in  a  ])atholo<;ical  sense  there  is  no  true  hyper- 
trophy, and  1  prefer  to  retain  the  term  enlargement  simplx'  because 
the  actual  patholouical  ])rocess  at  work  in  these  cases  is  still  in  dispute, 


Fig.  9.5.5. — Diagram  of  a  sagittal  sec- 
tion througli  the  prostatic  urethra:  1. 
Sphincter  of  bladder  (internal) ,  posterior 
segment.  2.  Pre-spermatic  portion  of 
prostate.  3.  Ejaculatory  ducts.  4. 
Retro-spermatic  portion  of  prostate.  5. 
Urethra.  6.  Vesical  orifice  of  urethra. 
7.  Internal  sphincter  of  bladder,  anterior 
segment.  8.  Suburethral  or  paraureth- 
ral glands  (group  of  verumontanum).  9. 
External  sphincter  of  the  bladder.  (After 
Cuneo.) 


Fig.  956. ^Diagram  of  a  sagittal  section 
of  the  prostatic  urethra,  in  a  case  of  "en- 
largement of  the  prostate:"  1.  Enlarge- 
ment (adenoma)  of  the  suburethral  glands 
(Fig.  955,  8).  2.  Internal  sphincter  of 
the  bladder,  posterior  segment.  3.  Retro- 
spermatic  portion  of  the  prostate.  4. 
Ejaculatory  ducts.  5.  Pre-spermatic  ijor- 
tion  of  prostate.  6.  Lateral  lobes  of 
tumor  (adenoma  of  suburethral  glands). 
7  External  sphincter  of  bladder.  8.  In- 
ternal sphincter  of  bladder,  anterior 
segment.  9.  Neck  of  bladder.  10. 
Bladder.    (After  Cuneo.) 


and  because  it  is  the  mechanical  effect  of  the  enlargement  of  the 
gland  (urinary  ohsirudion)  which  makes  the  condition  important 
surgically.  The  modern  hypothesis,  put  forward  by  ^Nlotz  and  Per- 
earnau  in  1905,  and  supported  by  researches  of  E.  ]\Iarquis  (1910) 
and  Cuneo  (1913),  is  to  the  effect  that  so-called  enlargement  of  the 
prostate  is  not  an  affection  of  the  prostate  at  all,  but  of  the  suburethral 
glands,  lying  beneath  the  urethra  immediately  on  the  vesical  side  of 
the  ejaculatory  ducts  {Y\g.  955).  According  to  this  theory,  the  change 
is  truly  neoplastic  (adenomyoma),  and  the  tumor  displaces  and  con- 
denses the  prostate  beneath  and  around  it  as  a  sort  of  capsule  (Figs. 
95()  and  957).     Though  this  is  in  accord   with  the  facts  that   in 


1030 


SURGERY  OF  THE   URETHRA   AND  PROSTATE 


Fig.  957. — Diagram  showing  in  transverse 
section  the  relation  of  the  periurethral 
adenoma  to  the  prostate:  1.  Capsule  of  the 
prostate.  2.  Urethra.  3.  Prostate,  com- 
pressed and  pushed  aside  by  the  new  growth. 
4.  Ejaculatory  ducts.  5.  Adenomyoma 
(After   Cuneo.) 


"enlargement  of  the  prostate"  the  ejaculatory  ducts  are  depressed  far 
toward  the  rectal  aspect  of  the  tumor,  and  that  the  lengthening  of 
the  urethra  occurs  solely  in  tiint  jxjrtion  between  the  verumontanum 
and  the  bladder  (there  is  no  lengthening  of  the  segment  of  the  pros- 
tatic urethra  on  the  distal  side  of  the  verumontanum),  nevertheless 
this  theory  has  not  yet  gained  very  wide  acceptance. 

Clinically  there  are  tw^o  seemingly  distinct  forms  of  enlargement 
of  the  prostate:  in  one  the  change  in  the  prostate  appears  to  be  adeno- 
matous in  character,  and  the 
prostate  becomes  large,  soft,  or 
of  only  moderate  hardness; 
while  in  the  other  a  sclerosis 
exists,  as  if  caused  by  a  chronic 
inflammatory  process,  and  the 
prostate  does  not  become  very 
large.  I  believe  there  is  no 
good  evidence  that  this  fibrous 
type  of  enlargement  is  a  later 
stage  of  the  adenomatous  form, 
though  this  is  the  teaching  of 
Moullin  and  some  other  author- 
ities on  the  subject.  I  believe 
it  is  much  more  probable 
that  the  adenomatous  form  of 
enlargement  is  an  "adenomatosis"  of  the  prostate  (or  rather  of  the 
suburethral  glands),  or  even  a  true  adenomyoma;  while  the  small 
sclerotic  prostate  is  the  result  of  chronic  injection,  and  should  be  classed 
entirely  apart.  Ciechanow\ski  (1900)  and  others  since  his  time  have 
sought  to  show  that  all  cases  of  enlargement  of  the  prostate  were 
originally  inflammatory  in  origin,  the  main  causative  factor  being 
the  gonococcus. 

A  prostate  which  is  the  seat  of  the  adenomatous  type  of  enlarge- 
ment usually  presents  on  section  numerous  "prostatic  tumors"  which 
compress  the  surrounding  stroma  into  a  capsular  envelope,  and  which 
grow  in  the  direction  of  least  resistance  (toward  the  bladder) ;  here  they 
often  project  beneath  the  mucous  membrane  posterior  to  the  urethral 
orifice,  and  are  termed  (wrongly)  "median  lobe"  enlargements.  In 
some  cases  the  enlarged  prostate  presents  no  such  distinct  tumor 
masses  in  its  interior,  but  exhibits  general  glandular  or  fibrous 
enlargement,  or  a  combination  of  the  two  forms.  The  small,  hard, 
sclerotic  prostate  usually  is  densely  adherent  to  surrounding  struc- 
tures, and  these  evidences  of  former  peri-prostatitis  lend  support  to  the 
view  that  such  prostates  have  been  altered  by  chronic  inflammatory 
changes. 

Any  prostate  weighing  more  than  six  drams  (23  grams)  may  be 
considered  abnormal.  From  this  size  they  range  up  to  12  ounces  or 
more.  The  average  weight  of  prostates  removed  at  operation  is  about 
3  ounces.    Enlargement  occurs  chiefly  in  an  anteroposterior  direction, 


ENLARGEMENT  OF   THE   I'ROSTATE  1031 

and,  as  the  ajK'x  of  the  i)r()stato  is  fixed  against  the  triangular 
ligament,  growtii  oecurs  ehiefly  toward  the  vesieal  eavity.  The  two 
lateral  lobes  usually  are  not  equally  enlarged,  and  this  aeeounts  for  a 
rather  constant  de\'iati()n  of  the  urethra  to  one  or  other  side.  The 
two  lateral  lohes  may  project  into  the  bladder  in  such  a  form  that 
the  urethral  orifice  resembles  the  os  uteri;  or  as  already  mentioned, 
a  "prostatic  tumor"  may  force  its  way  through  the  capsule  of  the 
prostate  and  project  beneath  the  vesical  nnicous  membrane  as  a 
nipi)le-like  obstruction  or  as  a  pedunculated  out-growth  behind  the 
vesical  orifice  of  the  urethra. 

Clinical  Pathology. — As  the  prostate  gland  enlarges,  various  changes 
are  j)roduced  in  the  urethra,  bladder  and  rectum;  and  less  directly 
in  the  urine,  kidneys,  and  general  health. 

Changes  in  the  Urethra. — The  length  of  the  normal  urethra  averages 
8  inches;  but  in  enlargement  of  the  prostate  the  length  rnay  he  14  or  16 
inches,  the  increase  occurring  in  the  prostatic  portion  of  the  canal, 
especially  in  that  portion  on  the  vesical  side  of  the  ejaculatory  ducts. 
This  fact  also  explains  the  elevation  of  the  vesical  orifice  of  the  urethra 
and  the  increased  curve  of  the  prostatic  urethra,  necessitating  a  special 
curve  to  inflexible  instruments  (Fig.  958,  3  and  4).  Lateral  deviation 
of  the  urethra  has  been  mentioned  above.  In  some  cases  a  peduncu- 
lated enlargement  at  the  vesical  orifice  produces  a  Y-shaped  channel. 
Increase  in  length  of  the  posterior  w^all  of  the  prostatic  urethra  may 
increase  its  antero-posterior  diameter  and  consequently  its  capacit}', 
so  that  it  may  hold  an  ounce  or  two  of  urine;  this  is  rare,  but  should 
be  remembered  as  a  possibility,  since  evacuation  of  a  small  amount 
of  urine  from  the  dilated  prostatic  urethra  may  lead  the  inexperienced 
to  think  the  catheter  has  entered  the  bladder. 

The  most  important  change  in  the  bladder  is  the  formation  of  a 
post-prostatic  pouch,  due  to  combined  elevation  of  the  urethral  orifice 
and  descent  of  the  vesical  floor.  The  greater  the  obstruction  to  the 
outflow^  of  urine  the  larger  this  pouch  becomes,  and  the  more  residual 
urine  collects  in  it.  Residual  urine  is  that  which  remains  in  the  bladder 
after  the  patient  has  expelled  all  he  can.  At  first  some  hypertrophy 
of  the  vesical  walls  may  occur,  but  if  obstruction  is  unrelieved  dilata- 
tion and  atrophy  ensue,  and  the  quantity  of  residual  urine  gradually 
increases.  This  state  of  chronic  incomplete  retention  of  urine  without 
distention  of  the  bladder  (stage  of  residual  urine)  is  finally  succeeded 
by  the  same  condition  with  distention  of  the  bladder,  and  when  the 
limit  of  the  bladder's  capacity  has  been  reached,  overflow  occurs 
(retention  with  overflow).  The  distinction  betw'een  the  latter  condition 
and  true  incontinence  of  urine  has  been  explained  at  p.  599.  But 
cystitis  may  occur,  and  then  the  bladder  does  not  dilate;  its  walls 
become  thickened  and  its  capacity  diminished.  Vesical  irritability 
demands  frequent  evacuation,  and  retention  with  overflow  is  rare. 
The  adenomatous  type  of  enlargement  usually  is  associated  with  a 
dilated  bladder;  while  where  cystitis  and  contraction  of  the  bladder 
are  present  the  prostate  usually  is  small  and  fibrous. 


1032  SURGERY  OF  THE   URETHRA  AXD  PROSTATE 

The  effects  on  the  kidneys  and  ureters  are  those  usual  in  other  cases 
of  urhiary  obstruction,  with  or  without  infection  (p.  975). 

The  residual  urine  almost  invariablj^  become  alkaline,  and  invites 
the  occurrence  of  cystitis,  but  if  acute  retention  does  not  occur, 
and  catheterization  is  avoided,  the  occurrence  of  cystitis  may  be  long 
postponed.  Phosphatic  calculi  frequently  form,  but  as  they  are  more 
or  less  fixed  in  the  retroprostatic  pouch  may  cause  no  characteristic 
symptoms. 

Effects  on  Urination. — Residual  urine  diminishes  the  capacity 
of  the  bladder;  hence  urination  must  be  more  frequent.  Frequent 
urination  increases  the  existing  congestion;  this  in  turn  may  bring 
on  retention  of  urine;  catheterization  is  resorted  to,  once  or  oftener, 
and  cystitis  is  the  usual  consequence.  The  retention  and  the  infection 
produce  nephritis,  the  quantity  of  urine  is  increased,  and  this  causes 
still  more  frequent  calls  to  evacuate  the  bladder.  In  this  way  a  vicious 
circle  is  produced,  and  unless  the  original  cause  of  all  this  woe,  uri- 
nary obstruction,  is  removed,  the  patient's  general  health  quickly 
deteriorates.  Dilatation  of  the  bladder  and  changes  in  its  walls  cause 
feeble  power  of  expulsion,  and  slowness  in  completing  the  urinary 
act;  while  the  inability  of  the  vesical  neck  to  act  properly  and  the 
interference  with  the  action  of  muscles  around  the  membranous  urethra 
cause  the  last  portions  of  urine  to  be  voided  in  dribbles,  no  power 
remaining  of  evacuating  it  in  spurts. 

Effects  on  the  Rectum. — The  rectum  may  be  obstructed  by  an 
enlarged  prostate,  causing  increasing  difficulty  in  defecation;  and  the 
constant  straining  in  micturition  is  a  frequent  cause  of  hemorrhoids 
and  pr(.)lap-^us. 

Symptoms  and  Clinical  Course. — Symptoms  seldom  are  observed 
before  the  age  of  fifty  years,  but  usually  enlargement  is  present  for 
some  time  before  notable  symptoms  are  produced.  Usually  the 
disease  is  insidious  in  onset,  and  the  first  abnormality  noted  is  noc- 
turnal frequency  of  urination.  Urination  probably  is  as  frequent  by 
day,  but  does  not  arrest  attention.  Sometimes  involuntary  dribbling 
of  urine  is  the  first  sign  of  trouble,  usually  due  to  retention  with  over- 
flow. Occasionally  acute  retention  is  the  first  symptom.  Starting 
the  stream  is  difficult,  because  there  is  both  increased  obstruction  to  be 
overcome,  and  decreased  expulsive  power;  the  stream  tends  to  drop 
vertically  from  the  meatus;  a  longer  time  than  usual  is  required  to  pass 
the  urine,  though  the  amount  evacuated  each  time  may  be  small; 
and  the  urine  dribbles  at  the  end  of  the  act  of  urination.  Retortion  of 
urine  is  noticed  by  the  patient  only  when  acute,  or  when  the  chronic 
form  is  accompanied  by  overflow.  The  symptoms  of  cystitis  and  renal 
complications  need  not  be  detailed  here.  Hematuria  seldom  occurs 
spontaneously,  but  may  follow  the  most  gentle  catheterization,  from 
rupture  of  varicose  urethral  or  vesical  veins. 

Patients  with  enlarged  prostates  may  be  divided  roughly  into  three 
classes  (Deaver  and  Ashhurst,  1905):  in  the  earliest  stage  the  chief 
complaint  is  nocturnal  frequency  of  urination;  in  the  second  stage 


ENLARGEMENT  OF   THE  PROSTATE  103/1 

patients  suffer  ocoasionall,\  from  complete  retention,  hut  ;ire  not  inucli 
trouhled  by  cystitis  and  enjoy  fairly  <;oo(l  health;  while  in  flir  third 
sfiuir  urinary  retention  is  nearly  absolute,  the  bladder  cannot  be  e\ac- 
iiated  without  a  catheter,  the  kidneys  are  markedly  diseased,  and  the 
patients  are  on  the  xerj^e  of  the  f:;rave. 

Diagnosis. — 1  )iagnosis  of  enlargement  of  the  prostate  cannot  be 
made  from  the  symptoms  alone;  physical  examination  is  retjuired. 
The  first  and  most  important  sign  to  be  looked  for  is  a  distenrled 
bladder;  neglect  to  observe  this  sign,  and  the  hasty  and  injudicious 
introduction  of  a  catheter  in  cases  of  long  standing  retention  with 
o\erHow  may  cause  immediate  syncope  (from  decrease  of  intra- 
abdominal pressure),  and  may  lead  in  a  few  days  to  the  patient's 
death  from  renal  congestion  and  uremia.  The  proper  treatment  of 
retention  with  o^•erflow  is  given  at  p.  1035.  Having  noted  the  absence 
of  a  distended  bladder,  request  the  patient  to  pass  all  the  urine  he 
can,  and  note  the  facility  with  which  he  starts  the  stream,  the  force 
with  which  it  is  expelled,  and  the  presence  or  absence  of  dribbling 
at  the  end  of  urination.  The  amount  of  urine  passed  should  be  meas- 
ured, and  the  habitual  frequency  of  urination  noted.  A  patient  who 
passes  four  ounces  of  urine,  more  or  less,  every  two  hours,  probably 
has  no  serious  renal  lesion.  If  he  passes  four  ounces  only  every  three 
or  four  hours,  either  the  normal  amount  is  not  excreted  by  the  kidneys 
or  the  quantity  of  residual  urine  is  rapidly  increasing.  If  on  the  other 
hand  half  an  ounce  or  an  ounce  is  passed  every  ten  or  fifteen  minutes, 
the  kidneys  will  be  excreting  from  50  to  150  ounces  of  urine  daily, 
and  retention  with  overflow  probably  exists.  If  the  bladder  is  not 
distended,  the  surgeon  should  next  insert  a  catheter,  to  ascertain  the 
quantity  of  residual  urine.  For  diagnostic  purposes  (not  for  treat- 
ment by  catheterism,  p.  1034)  I  prefer  a  metallic  instrument,  since  it 
acts  also  as  an  exploratory  sound.  As  this  is  passed,  note  the  presence 
or  absence  of  strictures,  any  deviation  of  the  subpubic  urethra,  the 
height  to  which  the  vesical  orifice  is  raised,  and  the  distance  from  the 
external  urinary  meatus  at  which  urine  begins  to  flow\  ThefoUmving 
facts  favor  the  diagnosis  of  enlarged  prostate:  if  the  shaft  has  to  be 
depressed  unduly  between  the  patient's  thighs  before  urine  flows, 
indicating  elevation  of  the  vesical  orifice  of  the  urethra;  if  the  urinary 
distance  (that  from  the  meatus  to  the  point  at  which  urine  commences 
to  flow)  is  increased  above  8  inches;  if  the  catheter  deviates  laterally 
in  the  prostatic  urethra;  or  if  the  catheter  meets  an  obstruction  more 
than  7  inches  from  the  meatus,  showing  the  obstruction  is  further 
back  than  the  usual  site  of  strictures.  A  small  amount  of  urine 
evacuated  from  the  dilated  prostatic  urethra  should  not  deceive  the 
examiner  into  thinking  the  bladder  has  been  reached. 

The  amount  and  character  if  the  residual  urine  are  now  noted;  and 
finally  a  few  ounces  of  saline  solution  are  injected  into  the  bladder, 
and  the  metal  catheter  is  used  very  gently  as  a  sound  to  explore  the 
condition  of  the  vesical  walls  and  to  search  for  calculi  in  the  post- 
prostatic  pouch.    Before  the  catheter  is  removed,  insert  a  finger  into 


1034  SURGERY  OF  THE   URETHRA  AND  PROSTATE 

the  rectum  and  palpate  the  prostate;  the  intravesical  instrument 
can  then  be  regarded  as  a  very  long  finger,  and  the  prostate  can  be 
palpated  between  this  and  the  finger  in  the  rectum. 

Treatment. — This  may  be  discussed  under  the  headings:  (1)  General 
treatment;  (2)  palliati\'e  treatment,  which  includes  catheterism  and 
certain  palliative  operations;  and  (3)  radical  treatment  by  prosta- 
tectoni}'. 

1 .  General  Treatment  is  important.  Especial  attention  should  be 
paid  to  diet,  to  hygiene,  and  to  securing  free  evacuation  of  the  bowels. 
Cascara  or  some  similar  laxative  is  to  be  preferred.  Atropin  never 
should  be  given  long  at  a  time,  for  fear  of  increasing  vesical  atony; 
hence  the  popular  A.  B.  &  S.  pills  should  be  avoided.  Drugs  are  not 
of  much  value  for  the  prostatic  condition,  but  during  an  accession  of 
prostatic  and  vesical  congestion  the  use  of  a  prescription  such  as  that 
advised  at  p.  907,  for  a  "fit  of  the  piles,"  often  procures  marked  relief. 
The  urine  should  be  kept  acid,  by  administration  of  benzoic  acid 
in  5  grain  doses,  with  twice  the  quantity  of  sodium  borate  to  ensure 
solution;  and  if  the  urine  is  not  too  acid  urotropin  is  the  best  anti- 
septic. For  excessively  acid  urine  it  is  best  to  increase  the  ingested 
fluid,  to  decrease  the  sugars,  and  to  administer  alkaline  salts  of 
potassium  or  sodium. 

2.  Palliative  Treatment. — Catheterism  consists  in  periodical  evac- 
uation of  the  residual  urine  by  use  of  a  catheter.  This  will  cure  no 
patients,  but  may  promote  their  comfort,  and  in  the  very  aged  or 
feeble  may  even  prolong  life.  As  the  expectation  of  life,  however, 
in  patients  treated  by  catheterism  is  in  the  average  no  more  than  four 
or  five  years,  it  is  clear  that  the  life  of  the  average  patient  is  shortened 
by  such  treatment.  I  do  not  recommend  it  except  when  prostatectomy 
is  contraindicated.  The  frequency  of  catheterization  depends  entirely 
upon  the  distress  occasioned  by  residual  urine,  yromded  the  latter  is  not 
increasing  in  quantity.  As  a  general  rule  a  patient  with  4  ounces  of 
residual  urine  requires  to  be  catheterized  once  in  twenty -four  hours; 
the  best  time  is  just  before  going  to  bed.  If  6  ounces  are  present,  use 
the  catheter  twice,  night  and  morning,  and  add  one  more  catheter- 
ization for  each  additional  2  ounces  of  urine  up  to  six  times  daily. 
When  the  required  number  of  catheterizations  exceeds  this  limit, 
some  other  form  of  treatment  is  urgently  demanded,  even  though 
catheterism  appears  to  maintain  the  patient's  general  health. 

Catheters  for  use  in  cases  of  enlarged  yrostate  should  be  14  to  16  inches 
long.  If  there  is  difficulty  in  introducing  the  usual  soft  rubber  catheter, 
it  is  possible  usually  to  insert  a  Mercier  catheter;  this  is  one  made  of 
webbing,  like  the  English  catheter  (p.  958) ,  but  having  the  point  set  at  an 
angle  of  110  degrees  with  the  shaft  (Fig.  958, 1 ) .  This  elbow  facilitates 
the  point  of  the  catheter  riding  over  the  prostatic  obstruetion,  the 
point  of  the  instrument  being  made  to  follow  the  roof  of  the  urethra. 
A  double  elboived  catheter  may  be  useful  at  times.  If  neither  of  these 
can  be  inserted,  an  English  catheter,  moulded  to  the  proper  "prostatic 
curve,"  as  advised  at  p.  959,  may  be  used.    If  it  will  not  pass  without 


ENLARGEMENT  OF   THE  PROSTATE  1035 

the  stylet,  it  should  he  reiutroihiced  with  the  ox-er-curxcd  styh't  in  its 
interior;  wUvw  the  ohstrnetion  is  met,  the  stylet  may  he  withdrawn 
uhout  halt'  an  inch,  thus  raising;  the  point  of  the  instrument  over  the 
obstruetion  (I'hysick.  ISIS)  (Fig-  95S,  'A).  A  metal  prostatic  catheter 
is  ad\isal)Ie  only  where  the  tissues  are  so  hard  and  resistant  from 
lon>;-stanilin<2;  inflannnation,  that  flexible  instruments  are  not  strong 
enough  to  ])ush  apart  the  sclerosed  structures.  If  the  i)atient  has  to 
catheterize  liimself  a  metal  catheter  never  should  be  allowed;  the  best 
instrument  is  the  soft  rubber  catheter,  next  the  Mercier  or  the  Eng- 
lish. The  ])atient  should  be  drilled  freciuently  in  the  necessary  aseptic 
techni(iue,  care  of  the  catheters,  and  their  introduction.  Only  intel- 
ligent and  careful  patients,  willing  to  devote  the  necessary  time  to 
the  matter,  will  succeed  in  avoiding  the  prompt  occurrence*  of  cystitis, 
which  is  eventuallv  nearlv  inevital)le. 


Fig.  958. — Prostatic  catheters:  1.  Mercier's  coude  (elbowed)  catheter.  2.  Bi-coude, 
or  double  elbowed  catheter.  3.  English  catheter  mounted  on  an  over-curved  stylet; 
when  the  stylet  is  partly  withdrawn  the  catheter  assumes  the  form  indicated  by  the 
dotted  lines.     4.   Metal  catheter,  with  prostatic  curve. 

Besides  the  occurrence  of  cystitis,  the  treatment  of  which  is  dis- 
cussed at  p.  9()3,  certain  other  complications  are  not  unusual.  Acute 
complete  retention  of  urine  is  treated  by  immediate  catheterization. 
There  is  great  danger  in  delay,  and  the  chance  of  the  retention  being 
overcome  by  palliative  measures  is  very  much  less  than  in  cases  of 
acute  retention  from  stricture.  In  chronic  complete  retention  of  urine 
the  bladder  should  be  drained  by  a  permanent  catheter,  in  the  hope 
that  the  cause  is  atony  of  the  bladder,  which  may  be  relieved  by  con- 
stant drainage.  If  retention  persists  after  atony  has  been  relieved  in 
this  way,  or  if  atony  is  not  relieved  by  the  drainage,  it  will  be  advisable 
either  to  remove  the  prostate  or  to  establish  a  suprapubic  vesical 
fistula  (see  below).  The  treatment  of  residual  urine  (chronic  incom- 
plete retention  of  urine,  without  distention  of  the  bladder)  has  been 
considered  at  p.  1034.  Finally  there  may  be  retention  with  overflow 
(chronic  incomplete  retention  of  urine  with  distention  of  the  bladder) : 
here  immediate  and  complete  withdrawal  of  the  urine  from  the  bladder 
is  considered  inadvisable,  since  experience  has  showai  that  sudden 
relief  of  intravesical  pressure  usually  is  followed  by  hematuria  from 
rupture  of  veins  in  the  bladder  walls,  and  is  frequently  followed  by 
the  development  of  surgical  kidneys,  uremia,  coma,  and  death,  within 


1036  SURGERY  OF  THE   URETHRA  AND  PROSTATE 

a  few  days.  It  is  prol)able  that  the  danger  in  such  cases  hes  in  the 
intermittent  catheterization  that  has  usually  been  employed,  since 
this  increases  the  chances  of  infection,  and  since  Cabot  (1908)  showed 
that  constant  drainage  by  the  use  of  an  inlying  catheter  was  able  to 
avert  threatening  fatalities  from  such  causes.  Hence  the  surgeon 
either  should  adopt  Cabot's  plan  or  should  adhere  to  the  time-honored 
custom  of  evacuating  such  over-distended  bladders  by  degrees,  with- 
drawing only  a  few  ounces  at  a  time;  or  if  all  the  urine  is  drawn 
at  once,  and  an  inlying  catheter  is  not  retained,  he  should  replace 
most  of  the  fluid  withdrawn  from  the  bladder  by  saline  solution. 

Among  palliative  operations  the  formation  of  a  suprapubic  fistula 
holds  first  place.  This  was  popularized  in  1S88  by  Hunter  jMcGuire; 
the  operation  resembles  that  of  su})ra]>ubic  cystotomy  (p.  970). 
Where  urethral  obstruction  is  marked,  there  is  no  likelihood  of  the 
suprapubic  fistula  closing,  but  when  this  tendency  is  observed  a  rubber 
tube  should  be  worn  constantly  in  the  fistula.  At  the  time  of  the 
operation  any  calculi  present  may  be  removed,  but  no  attempt  should 
be  made  to  remove  the  prostate  in  such  feeble  patients  as  those  for 
whom  this  jjalliative  operation  is  advisable.  Siter  (1912),  however, 
has  found  that  dilatation  of  the  vesical  orifice  of  the  urethra,  by  the 
insertion  of  the  surgeon's  finger  through  the  suprapubic  wound,  may 
secure  almost  as  much  relief  (even  if  only  temporary)  as  a  formal 
prostatectomy,  and  may  be  resorted  to  without  materially  prolonging 
the  operation  or  increasing  its  gravity.  If  a  pedunculated  prostatic 
out-growth  is  found  acting  as  a  ball-valve  against  the  vesical  orifice 
of  the  urethra,  it  should  be  removed;  if  no  other  urethral  obstruction 
exists  (a  point  readily  determined  by  passing  a  soft  catheter)  this 
may  effect  permanent  relief  of  all  symptoms.  In  some  cases  where 
the  prostate  is  small  and  atrophic,  and  the  bladder  thickened  and 
contracted,  much  relief  may  be  secured  by  median  perineal  cystotomy, 
with  incision  of  the  prostate  and  dilatation  of  the  prostatic  urethra 
(perineal  prostatotomy) ;  a  perineal  tube  is  retained  until  a  permanent 
fistula  is  assured.  After  either  suprapubic  or  perineal  drainage  a  fair 
measure  of  continence  is  secured;  and  constant  drainage  by  an  in- 
lying catheter  will  be  available  whenever  demanded  by  the  occurrence 
of  cystitis. 

The  Bottini  operation  was  introduced  in  1874,  but  little  used  until 
popularized  by  Freudenberg  in  1897.  It  consists  in  making  incisions 
in  the  prostate  by  a  galvano-cautery  introduced  through  the  urethra. 
The  subsequent  cicatrization  and  contraction  of  these  incisions  may 
reduce  the  size  of  the  prostate  and  thus  overcome  urinary  obstruction; 
or  they  may  fail  to  do  so.  The  operation  is  uncertain  in  its  results, 
the  good  effects  sometimes  secured  are  not  permanent,  and  the  mor- 
tality is  no  lower  than  that  of  prostatectomy  in  skilled  hands. 

3.  Radical  Treatment  consists  in  removal  of  the  prostate.  It  is 
the  treatment  of  choice,  and  should  be  adopted  in  every  case  ex-cept 
where  distinct  contraindications  exist.  The  chief  contraindications 
are  severe  cystitis  and  renal  insufficiency;  and  these  usually  may  be 


I'liOSTATECTOMY 


1037 


overcome  by  preliminary  treatment,  wliicli  may  inehulc  some  of  the 
palliative  operations  already  discussed,  notably  sui)rapubic  drainage 
of  the  bladder.  Extreme  age  is  not  a  contraindication,  but  if  such 
patients  can  be  kept  comfortable  by  catheter  life,  it  will  not  be 
advisable  to  resort  to  prostatectomy. 

Two  methods  of  operation  are  in  common  use:  the  suprapubic, 
introduced  in  1887  by  McGill  of  Leeds,  and  improved  and  popularized 
in  11)01  by  Freyer,  of  London;  and  the  jjeriiiral,  which  was  a  gradual 
development  of  the  i)ractice  of  perineal  prostatotomy  (a  common 
practice  in  the  early  part  of  the  last  centur\),  and  which  was  employed 
first  in  cases  of  malignant  disease  during  the  decade  from  1870  to 
1880.  Its  modern  de\'elopment  is  due  largely  to  the  labors  of  the 
French  school,  headed  by  Albarran,  and  to  its  exi)loitation  in  this 
country  by  Dr.  II.  II.  Young,  of  Johns  Hopkins  University. 


/h6o-j:>ro5ta^ic  //.^amenJ 


J^er/'toneum 


oneurosls  °/I?fi/2onuil^f.ers 


jrostate 
Ant.  lai/er "/  Tr^a/i^ular  /ijament 


Fig.  959. — Sheath  of  prostate  in  sagittal  section  (diagrammatic).      (Deavcr  and 

Ashhurst.) 


For  cases  of  enlarged  prostate  of  the  adenomatous  type  (the  immense 
majority)  suprapubic  prostatectomy  (Freyer)  is  preferable;  but  where 
the  prostate  is  dense,  and  adherent  to  surrounding  structures,  and 
where  the  bladder  is  small  and  contracted,  the  operation  is  best  done 
through  the  perineum,  as  it  will  be  impossible  to  shell  out  the  organ 
as  is  done  in  the  suprapubic  operation.  , 


1038 


SURGERY  OF  THE   URETHRA  AND  PROSTATE 


Suprapubic  Prostatectomy. — The  prostate  lies  upon  the  triangular 
ligament  and  above  the  aponeurosis  of  Denonvilliers  (Fig.  959); 
neither  of  these  structures,  so  important  in  completing  the  floor 
of  the  pelvis,  is  divided  when  the  prostate  is  lifted  off  them  and 
delivered  into  the  cavity  of  the  bladder.  When  the  prostate  is  adeno- 
matous its  enucleation  in  this  manner  is  accomplished  with  surprising 


^ecto-Desical  fascia  "^'-^s^s^v. 
Jst.Di.  vision   ^^^    j  \ 
,2 /id.  Dtuisfon  ^  j 
3rd.  Division  ^ 


06lurator 
Intemi/.s 

Analjascicc- 
ZeoaforAni 


\  \      vessels Smrue: 


Fk 


960. — Sheath  of  prostate  in  transverse  section.     Line  of  section  shown  in  the 
lower  drawing  (diagrammatic.)      (Deaver  and  Ashhurst.) 


ease.  The  enlarged  prostate  projects  into  the  bladder,  and  is  covered 
only  by  mucous  membrane  or  at  most  by  attenuated  muscular  tissue 
which  is  as  much  prostatic  capsule  as  it  is  vesical  wall.  Enucleation 
takes  place  theoretically  between  the  proper  prostatic  capsule  (con- 
densed  by   the   eccentric  enlargement   of  the    "prostatic   tumors") 


SUPRA  rCJilC  r  HOST  A  TKCTOM  Y 


irno 


and  its  slicatli,  fonnrd  by  partitions  of  tiie  rectovesical  fascia  (Fi^. 
[){')()).  It  is  not  unlikely,  however,  that  in  many  cases  the  enucleation 
takes  place  within  the  layers  of  the  true  prostatic  capsule,  much  as  the 
heart  of  an  onion  may  be  shelled  out,  leaviiifj  the  outer  layers  intact. 
Tlic  bladder  is  opened  as  in  snpra])nl)ic  cystotomy  (j).  070),  and  to 
assist  subsequent  manipulations  the  index  and  middle  fingers  of  one 
hand  (gloved)  are  passed  into  the  patient's  rectum  (the  sj)hincter  hav- 
ing been  well  stretched  previously)  and  are  made  to  push  the  i)rostate 
u])  toward  the  su])raj)nl)ic  wound  (Fig.  WW  ).  The  surgeon  then  inserts 
a  finger  of  the  other  hand  into  the  ^•esical  orifice  of  the  urethra,  and 
breaks  through  the  mucous  membrane  covering  the  enlarged  prostate. 
The  natural  line  of  cleavage  is  found  without  much  trouble.     The 


Fig.  9(31. — Suprapubic  prostatectomy. 

finger  should  first  pass  to  the  outer  side  of  the  lateral  lobe  first  attacked, 
since  here  the  attachment  of  the  prostate  to  its  sheath  is  least  dense. 
Then  the  finger  cautiously  but  not  timidly  works  down  under  the 
lateral  lobe  toward  the  neighborhood  of  the  posterior  commissure 
and  the  ejaculatory  ducts.  Next  the  posterior  and  inferior  surfaces 
are  separated  from  the  sheath;  and  finally  when  the  lobe  is  pretty  well 
outlined  the  finger  may  pass  along  the  lateral  and  inferior  surfaces 
to  the  apex  of  the  lobe  and  free  this  from  the  triangular  ligament. 
At  times  the  lateral  lobe  first  attacked  comes  away  alone,  leaving 
the  urethra  still  attached  to  the  other  lobe.  More  often  the  vesical 
mucous  membrane  tears  during  this  enucleation,  and  the  vesical 
orifice  of  the  urethra  becomes  entirely  detached  by  extension  of  the 
tear  across  the  trigone  of  the  bladder.    Then  the  enucleating  finger 


1040 


SURGERY  OF  THE   URETHRA   AND  PROSTATE 


will  pass  across  to  the  other  lobe,  beneath  the  posterior  commissure 
of  the  prostate.  Finally,  when  enucleation  of  the  second  lobe  has 
been  completed,  the  prostate  is  found  fully  detached  from  surrounding 
structures,  except  where  the  urethra  annexes  it  to  the  triangular 
ligament.  At  this  stage  it  is  said  the  prostatic  urethra  may  slip  out 
of  the  prostate,  remaining  attached  to  the  triangular  ligament;  but 
what  usually  occurs  is  that  it  tears  off  just  on  the  vesical  side  of  the 
verumontanum,  and  is  removed  with  the  prostate.  The  anterior 
commissure  of  the  gland  may  give  away  during  these  manipulations, 
but  in  most  cases  the  prostate  is  removed  in  one  mass  (Fig.  9()2). 
It  is  then  withdrawn  from  the  bladder,  and  the  cavity  from  which 
it  has  been  enucleated  rapidly  contracts.  Bleeding  rarely  is  alarming, 
and  usually  is  rapidly  controlled  by  hot  douching.^  The  bladder  is 
then  closed  around  a  large  drainage  tube,  as  in  cases  of  suprapubic 
cystotomy.  The  tube  may  be  removed  in  four  or  five  days,  and  the 
patient  may  leave  his  bed  as  soon  thereafter  as  proves  agreeable  to 
him.  The  bladder  is  irrigated  once  daily  through  the  suprapubic 
wound  as  long  as  this  remains  open.  Should  it  show  no  tendency  to 
close  by  the  third  week,  a  catheter  should  be  passed  once  daily  by  the 


Fig.    962.— Eiihirw'd  prostate   nniovcd  l,y 
urethra  pointing  tovvurd  blailder.    Prostate  (^n 


ii|>ia])ubic  prostatectomy.      Catheter  in 
it-b  inferior  surface.     Episcopal  Hospital. 


urethra.  Removal  of  the  prostatic  urethra  will  have  shortened  the 
urethral  channel  considerably,  the  vesical  orifice  now  being  close  to 
the  triangular  ligament.  Stricture  formation  is  unusual.  The  chief 
dangers  are  shock  and  hemorrhage.  The  immediate  mortality  varies 
from  5  to  7  per  cent,  in  skilled  hands,  and  the  results  are  exceedingly 
good.  Voluntary  urination  is  restored;  no  residual  urine  remains; 
and  the  patient's  life  is  lengthened  by  many  years. 

Perineal  Prostatectomy  I  think  is  best  reserved  for  small  fibrous 
prostates.  The  best  exposure  is  gained  by  the  technique  of  the  French 
school,  elaborated  by  Proust  (1903).  The  patient  lies  on  his  back  with 
his  buttocks  raised  on  a  sand  pillow,  and  thighs  flexed  on  the  abdomen 
as  far  as  possible,  thus  inverting  the  pelvis  and  bringing  the  perineum 
nearly  horizontal.  A  staff  is  fixed  in  the  urethra,  and  through  a  trans- 
verse incision,  with  convexity  forward,  extending  from  one  ischiatic 
tuberosity  to  the  other,  the  perineal  centre  is  exposed.  Then  the 
attachment  of  the  external  sphincter  ani  to  this  is  divided,  and  the 

1  In  cases  of  persistent  bleeding  the  bed  of  the  prostate  may  be  packed  with 
gauze,  held  in  place  by  a  few  sutures  of  catgut  passed  through  the  free  edges  of 
mucous  membrane  forming  the  roof  of  the  cavity.  One  end  of  the  gauze  projects 
from  the  suprapubic  wound,  and  the  packing  can  thus  be  removed  as  soon  as  the 
catgut  sutures  are  absorbed  (Deaver  and  Ashhurst). 


PERINEAL  PROSTATECTOMY  It  141 

dissection  contimicd  i)()stori()r  to  the  transverse  perineal  nuiseles. 
By  (Irawinji  the  anns  toward  the  eoeeyx,  the  reeto-urethralis  muscle 
is  put  on  the  stretch;  and  hy  dividin*,'  this  close  to  the  inenihranous 
urethra  (which  is  not  opened),  the  surgeon  opens  the  si)ace  between 
the  two  layers  of  the  apcMieurosis  of  Denonvilliers  (Fig.  959),  known 
as  the  ''espacr  drrullahlr  rftroprosfatique.''  The  rectum  now  falls 
away  from  the  anterior  structures  and  ai)pears  like  a  loop  of  intestine 
floating  free  in  the  peritoneal  cavity;  it  is  covered  by  the  posterior 
layer  of  this  aponeurosis,  while  the  anterior  layer  still  covers  the  pros- 
tate and  seminal  vesicles.  It  is  to  be  recalled  that  the  aponeurosis 
of  Denonvilliers  really  is  an  obliterated  sac  of  peritoneum,  analogous 
to  the  processus  vaginalis  of  the  testicle. 

Beyond  the  anterior  layer  of  the  aponeurosis  of  Denonvilliers  the 
prostate  can  now  be  indistinctly  felt,  floating  away  as  soon  as  touched. 
The  urethra  therefore  is  opened,  at  the  apex  of  the  prostate;  a  pros- 
tatic tractor  is  inserted  into  the  bladder,  and  its  blades  are  turned  so  as 
to  catch  on  the  vesical  surface  of  the  prostate.  The  prostate  being  thus 
steadied,  its  sheath  (anterior  layer  of  the  aponeurosis  of  Denonvilliers) 
is  opened  over  one  of  the  lateral  lobes  of  the  prostate,  by  an  incision 
parallel  to  the  urethra.  By  the  finger  or  a  blunt  dissectc.r,  this  sheath 
is  then  stripped  from  each  lateral  lobe,  with  utmost  thoroughness. 
Proust  says  that  time  apparently  lost  at  this  stage  of  the  operation 
will  be  found  to  accelerate  matters  considerably  at  a  later  stage. 
When  the  prostate  is  thus  freed  of  all  its  attachments  except  to  the 
urethra  and  ejaculatory  ducts,  the  prostatic  tractor  is  removed,  and 
the  floor  of  the  urethra  is  split  open  from  the  apex  of  the  prostate 
back  to  but  not  into  the  neck  of  the  bladder.  This  cut  hemisects  the 
prostate  as  well,  and  each  lateral  lobe  in  turn  is  dissected  oft'  the  lateral 
and  upper  aspects  of  the  urethra,  by  scissors.  If  possible,  each  lateral 
lobe  is  removed  entire,  not  by  morceUement.  Proust  ligates  the  ejac- 
ulatory ducts,  thinking  this  lessens  the  chances  of  orchitis.  The  bladder 
is  drained  by  rubber  tube,  and  the  floor  of  the  prostatic  urethra  is 
sutured  over  this  as  a  guide,  as  far  forward  as  the  triangular  ligament, 
where  the  tube  emerges.  The  perineal  wound  is  drained  by  gauze 
wicks,  and  is  partly  closed  by  buried  sutures. 

Young  introduced  in  1903,  and  has  practised  in  a  large  series  of  cases 
with  surprising  success  and  wonderfully  low  mortality,  an  operation 
which  he  calls  "conservative"  perineal  prostatectomy.  The  technique 
is  much  the  same  as  that  of  the  French  school,  except  that  an  attempt 
is  made  to  preserve  the  ejaculatory  ducts  by  leaving  intact  the  pos- 
terior commissure  of  the  gland,  in  which  they  run.  It  seems  very 
doubtful  whether  this  feature  of  the  operation  is  of  any  value. 

Atrophy  of  the  Prostate  and  Contracture  of  the  Neck  of  the  Bladder 
(Chetwood,  1901).— Usually  these  occur  together,  and  are  the  result 
of  long  continued  inflammatory  changes.  The  sclerotic  type  of  pros- 
tatic enlargement,  already  described,  can  with  diflficulty  be  separated 
from  atrophy  of  the  gland.  The  symptoms  are  similar  to  those  seen 
in  enlargement  of  the  prostate,  since  the  sclerosis  of  the  ti.ssues  inter- 
feres with  urination.  Especially  frequent,  according  to  Young,  are 
66 


1042  SURGERY  OF  THE  URETHRA  AND  PROSTATE 

chronic  inflammatory  changes  in  the  prostatic  utricle.  Another  fre- 
quent factor  in  urinary  obstruction  in  these  cases  is  a  "bar  at  the  neck 
of  the  bladder"  (Guthrie,  1834)  usually  in  the  form  of  a  dense  fibrous 
ring  around  the  vesical  orifice  of  the  urethra.  Chronic  prostatitis 
usually  coexists.  The  diagnosis  is  made  by  recognizing  the  small 
sclerotic  prostate  on  rectal  examination,  and  by  use  of  the  cystoscope 
which  usually  shows  an  abnormal  condition  of  the  prostatic  urethra 
and  vesical  neck. 

Treatment. — Treatment  even  by  specialists  in  genito-urinary  sur- 
gery-, is  not  always  satisfactory.  The  condition  of  the  urine  should 
be  attended  to;  and  methods  already  advised  in  cases  of  chronic 
prostatitis  may  be  tried.  Best  results  follow  direct  treatment  of  the 
prostatic  urethra  through  the  cystoscope.  If  a  bar  at  the  neck  of  the 
bladder  is  found,  it  may  be  punched  out  by  one  of  the  modern  instru- 
ments copied  after  Mercier's  original  prostatotome  and  prostatectome 
(1837),  or  relief  may  be  secured  by  the  Bottini  galvano-cautery  opera- 
tion. Prostatectomy  (by  the  perineal  route)  may  be  considered  the  last 
resort. 

Carcinoma  of  the  Prostate  is  now  recognized  as  much  more  frequent 
than  formerly  supposed.  It  probably  occurs  in  not  less  than  10  per 
cent,  of  patients  who  complain  of  symptoms  of  urinary  obstruction 
from  prostatic  disease.  The  malignant  growth  appears  to  originate 
usually  in  that  portion  of  the  prostate  posterior  to  the  urethra  and 
below  the  ejaculatory  ducts.  It  tends  to  infiltrate  upwards  invading 
the  vasa  deferentia  and  seminal  vesicles  long  })efore  it  spreads  into 
the  prostatic  tissues  immediately  adjacent  to  the  neck  of  the  bladder. 
Patients  seldom  come  under  observation  while  the  growth  is  still 
operable.  In  some  cases  the  earliest  indication  of  trouble  is  not  the 
occurrence  of  local  symptoms,  but  the  discovery  of  metastasis  in  the 
bones  of  the  pelvis,  trunk,  or  thighs.  Usually  it  is  found  that  a  hard, 
nodular,  fixed  tumor  occupies  the  region  of  the  prostate,  and  that  the 
rectal  mucous  membrane  does  not  glide  easily  over  the  enlarged  organ 
as  is  the  case  in  benign  enlargement.  Peferred  pains  are  frequent  in 
advanced  cases. 

Treatment. — Treatment  usually  must  be  palliative.  A  radical  oper- 
ation, involving  removal  of  the  prostate  and  seminal  vesicles,  resection 
of  the  neck  of  the  bladder,  and  suture  of  the  membranous  urethra  to 
the  remaining  vesical  wall,  has  been  devised  and  practised  by  Young, 
with  fair  success.  Where  such  a  radical  operation  is  impracticable,  he 
has  practised  a  partial  perineal  prostatectomy  with  preservation  of  the 
urethra  and  vesical  mucosa;  he  thinks  that  in  about  60  per  cent,  of 
cases  excellent  functional  results  may  be  expected  Avhich  will  be 
maintained  so  long  as  the  patient  lives. 

Sarcoma  of  the  Prostate  is  rare.  A  tumor  in  a  child  or  yoimg  person 
probably  is  sarcomatous;  it  grows  very  rapidly,  and  almost  always  is 
inoperable.  The  earliest  symptom  often  is  complete  retention  of 
urine;  less  often  do  symptoms  of  incomplete  urinary  obstruction 
occur,  or  rectal  symptoms.  Death  occurs  within  three  months  to 
two  years. 


CHAPTER   XXVIII. 
SURGERY  OF  THE  MALE  GENITAL  ORGANS. 


SURGERY   OF   THE   PENIS. 

Congenital  Deformities. — Hpyospadias. — Tlie  most  frequent  of  these 
is  hypospaciias,  in  wliich  there  is  a  defect  in  the  floor  of  the  urethra, 
extending  from  the  meatus  a  variable  distance  backward.  It  occurs 
once  in  about  8()()  males,  and  is  due  to  failure  of  coalescence 
between  the  two  lateral  portions  of  the  penis  on  its  under  surface. 
In  glandular  hypospadias  the  urinary  meatus  is  displaced  only  slightly, 
and  unless  it  is  as  low  as  the  region  of  the  frenum  no  treatment  usually 
is  required.  In  penile  hypospadias  (Fig.  963)  the  opening  usually  occurs 
at  the  junction  of  tlie  penis  and  scrotum  (peno-scrotal  hypospadias) 
but  mav  be  anterior  to  this  site.     In  the  most  marked  deformity  the 


^M 

r  >  '"■^  ^  " 

H^l^^^^^^^l 

^H 

■ 

P 

Xk 

^ 

••^^i^f-'"'-  -" 

"^ 

Fig.  963. — Penile  hypospadias.     Episcopal  Hospital. 


opening  is  in  the  perineum,  there  is  usually  cleft  scrotum,  the  penis  is 
rudimentary,  and  there  is  resemblance  to  the  condition  known  as 
hermaphrodism.  In  all  cases  of  hypospadias  there  is  downward 
incurvation  of  the  penis,  and  the  prepuce  usually  is  abnormal  in  form 
or  attachment. 

Treatment. — Treatment  involves  some  form  of  plastic  operation, 
and  the  best  time  for  this  is  about  the  age  of  six  years.  It  is  very 
important  to  employ  only  such  skin  in  plastic  operations  as  will  remain 
free  from  hair  throughout  life.  In  most  cases  the  bladder  should  be 
drained  through  the  perineum  during  the  first  week  after  operation, 
or  until  the  sutured  structures  have  firmly  united.     In  glandular 


1044 


SURGERY  OF   THE   MALE  GENITAL  ORGANS 


hypospadias  Beck's  operation  (1907)  is  the  best  (Figs.  964  and  9()")) :  the 
urethral  orifice  and  about  an  inch  of  the  urethra  are  dissected  free,  and 


Fig.  964. — Beck's  operation  for  hypospad- 
ias.    (Watson  and  Cunningham.) 


Fig. 


965. — Beck's  operation, 
and  Cunningham.) 


(Watson 


the  glans  is  perforated  from  base  to  summit  by  a  bistoury,  this  tract 
is  dilated,  and  the  previously  mobilized  urethra  is  drawn  through  and 

the  meatus  sutured  in  its  normal  posi- 
tion. A  similar  operation  may  succeed 
when  the  urethral  opening  is  in  the  penis 
not  too  far  from  the  glans;  but  in  most 
cases  of  penile  and  in  all  cases  of  peno- 
scrotal and  perineal  hypospadias,  it  is 
necessary  to  construct  a  new  urethra  by 
skin  flaps.  A  good  method  in  cases  of 
peno-scrotal  hypospadias  is  to  outline 
two  corresponding  rectangular  flaps  from 
the  under  surface  of  the  penis  and  the 
anterior  median  raphe  of  the  scrotum,  re- 
spectively, as  indicated  in  Fig.  9(i6.  The 
denuded  edges  are  sutured  together, 
and  after  several  weeks,  when  union  is 
firm,  the  penis  with  the  adherent  scrotal 
raphe  (which  forms  the  floor  of  the  new 

urethra)  are  cut  free  from  the  scrotum,  and 
Fig. 966. — BueknaU's operation  for      ^i  ^  ]  •      i         r  ]• 

penoscrotal  hypospadias  (1907).      the  raw  surtaccs  are  covered  m  by  slidmg 


CONGENITAL   DEFOh'MiriF.S  OF   THE   PENIS 


i()4r) 


flaj>s  t(),i;;('tluT  From  the  sides,  or  hy  l)riii<;iii<f  the  rcduiidaiit  i>r('|)ucc  oxer 
the  under  surt'acc  ol"  the  j)eiiis  as  a  l)rid^e.  After  a  ])eiiile  iiretlira  has 
been  eonstructed  in  this  way,  it  max  he  transphmted  into  the  glans, 
aeeording  to  BiH'k's  operation,  on  a  snhsecpient  oeeasion.  C'antas 
(1911)  used  a  plastic  llaj),  with  ])edie]e,  Iroin  the  thi^di,  eontaininj^  a 
section  of  the  h)nii;  saphenous  \-ein,  which  serxcd  as  the  new  urethra. 


-Epispadias;  age  six  y 


Ki)iseopal  Hospital. 


Epispadias. — In  epispadias  the  roof  of  the  urethra  is  deficient  for 
a  greater  or  less  distance  back  from  the  normal  site  of  the  meatus 
(Fig.  9()7).  It  is  treated  by  operations  analogous  to  those  employed 
for  hypospadias.  Cantwell's  operation  (1895)  is  commended  by 
Binnie  (Fig.  968). 


Fig.  968. — Cantwell's  operation  for  epispadias:  a  new  urethra  is  formed  by  inverting 
skin-flaps;  the  corpora  cavernosa  are  then  separated  in  the  mid-line;  the  new  formed 
urethra  is  placed  in  the  floor  of  the  channel  thus  made;  and  finally  the  cavernous  bodies 
are  sutured  together  over  the  new  urethra. 


Hermaphrodism. — This  is  a  condition  in  which  an  individual  pos- 
sesses the  generative  organs  of  both  sexes.  It  is  excessively  rare;  in 
the  vast  majority  of  cases  only  false  hermaphwdism  exists:  a  male 
with  a  perineal  hypospadias,  cleft  scrotum,  rudimentary  penis,  and 
undescended  testicles  may  resemble  a  female  on  casual  inspection;  or  a 
female  with  abnormally  large  clitoris  and  congenital  absence  of  the 
vagina  may  resemble  a  male  hypospadiate.  Treatment  involves  opera- 
tive cure  of  the  predominant  deformity,  when  this  is  possible. 

Phimosis. — Phimosis  is  the  condition  in  which  the  prepuce  cannot 
be  retracted  over  the  glans.    It  is  rare  as  a  congenital  deformity,  most 


1046 


SURGERY  OF  THE  MALE  GENITAL  ORGANS 


Fig.  969. — Phimosis.     Age  sixteen  years. 
Episcopal  Hospital. 


cases  so  classed  being  merelj'  instances  of  adherent  prepuce  the  result 
of  balano-posthitis :  in  these  retraction  is  possible,  though  difficult. 
Cure  follows  daily  retraction,  cleansing,  and  application  of  zinc  oxide 
ointment  to  the  inflamed  parts.  Most  cases  of  true  phimosis  (Fig.  969) 
are  the  result  of  neglect  of  the  parts  in  infancy  and  early  childhood, 

the  preputial  orifice  re- 
maining infantile  in  size 
while  the  penis  has  con- 
tinued to  grow.  Mere 
i'lungation  or  redundancy 
of  the  prepuce  usually  is 
congenital  (Fig.  970).  In 
man}'  cases  phimosis  de- 
velops as  a  temporary 
condition  in  adult  life, 
as  a  complication  of  bal- 
ano-posthitis from  chan- 
croids or  gonorrhea. 

Treatment. — Treatment 
may  be  by  incision,  ex- 
cision, or  circumcision. 
Incision  (dorsal  slit  of  the 
prepuce)  was  mentioned  at  p.  1008;  it  is  used  mostly  in  cases  com- 
plicating balano-posthitis.  Excision  of  a  wedge  shaped  portion  of  the 
prepuce  is  seldom  or  never  employed.  Circumcision  is  the  typical 
operation.  Various  special  forceps  have  been  devised  to  simplify  the 
operation  but  their  place  is  readily  supplied  by  clamping  the  foreskin 
between  the  handles  of  a  pair  of  scissors,  the  redundant  foreskin  being 
cut  off  with  another  pair  (Fig.  971).  The  section  should  be  made 
obliquely,  removing  more 
tissue  from  the  dorsum  of 
the  penis  than  from  the 
region  of  the  freniun.  The 
clamp  should  be  applied 
at  a  level  which  corre- 
sponds with  the  sulcus  be- 
hind the  corona  glandis, 
and  the  skin  should  be 
drawn  well  in  front  of  the 
glans  before  the  clamp  is 
tightened.  ^Yhen  the  re- 
dundant tissue  is  cut  away 
and  the  clamp-  is  removed 

it  will  be  found  that  the  skin  surface  of  the  prepuce  retracts,  while 
its  mucous  layer  still  covers  the  glans.  The  mucous  layer  is  then 
slit  up  the  dorsum,  with  scissors,  as  far  as  the  corona  glandis.  It  is 
not  necessary  to  trim  off  the  triangular  flaps  of  mucosa  thus  formed, 
as  by  careful  suturing  no  redundant  tissue  is  left.     Next  ewry  bleeding 


Wmh^ 


Fig.  970. 


-Redundant  prepuce.     Children's 
Hospital. 


CIRCUMCISION 


1047 


})()int  shoiihJ  he  raiK/lit  in  hinnostafs  and  iKjatcd  with  fine  caff/nf.  Xcf^Icct 
of  this  procaiitioii  usually  results  in  t'orinatiou  of  a  hematoma  and 
hreakin*;  down  of  the  wound.  Finally  the  skin  and  mucous  layer  of 
the  i)repuee  are  sutured  to<ijether  with  interrupted  sutures  of  chromic 
cat";ut.    The  first  suture  is  introduced  at  the  frenum,  the  second  in 


Fig.  971. — Circumcision  with  two  pairs  of  scissors.      Episcopal  Hospital. 

the  mid-line  on  the  dorsum  of  the  penis,  the  third  and  fourth  at  the 
midpoints  on  the  right  and  left  sides,  and  such  other  intervening 
sutures  as  are  required  to  secure  neat  apposition.  The  ends  of  all 
these  sutures  are  left  long  after  tying,  and  the  dressing  (a  thin  roll  of 
gauze)  is  held  in  place  by  knotting  the  free  ends  of  the  sutures  over  it 


Fig.  972. — Dressing  for  circumcision.     Episcopal  Hospital. 


(Fig.  972).  This  roll  of  gauze  should  be  applied  a  little  slack,  so  as  not 
to  produce  strangulation  should  erections  occur.  No  other  dressing  is 
used.  In  the  course  of  ten  days  or  two  weeks  this  gauze  may  be 
peeled  off,  as  the  chromic  catgut  sutures  will  have  been  absorbed.  In 
the  meantime  the  seat  of  operation  requires  no  treatment. 


1048 


SURGERY  OF   THE  MALE  GENITAL  ORGANS 


Paraphimosis. — Paraphimosis  is  the  coiKhtion  in  which  the  foreskin 
has  been  retracted  over  the  ghms  and  cannot  he  replaced  owinji;  to 
swelling  of  the  glans  or  edema  of  the  foreskin  (Fig.  97.'^).  The  tightest 
band  of  constriction,  back  of  the  corona,  may  become  ulcerated  from 
pressure;  this  always  occurs  before  there  is  danger  of  strangulation 
of  the  penis. 

Treatment. — In  recent  cases  it  is  usually  ])ossible  to  reduce  the 
paraphimosis  by  pushing  the  glans  upward  with  the  thumbs,  while 
the    index    and    middle    fingers    of     both    hands,     applied     behind 

the  corona,  pull  the  foreskin 
forward.  If  reduction  is  not 
accomplished  in  this  way,  it 
is  often  advised  that  the  con- 
stricting band  be  divided;  but 
as  a  matter  of  fact  usually  no 
treatment  is  required  beyond 
bathing  the  parts  in  hot  water 
and  keeping  the  penis  elevated 
to  favor  reduction  of  the 
edema.  In  the  course  of  a 
few  days  the  foreskin  can  be 
drawn  down  again  in  most 
cases,  but  sometimes  perma- 
nent thickening  from  lymph- 
edema persists  and  may  re- 
cjuire  excision  or  circum- 
cision. 
Balanitis  and  Balano-posthitis. — Balanitis  is  inflammation  of  the 
glans  penis;  posthitis  is  inflammation  of  the  pre])uce.  Usually  both 
glans  and  prepuce  are  inflamed  (balano-posthitis).  In  children  this 
condition  is  a  frequent  complication  of  adherent  prepuce;  in  adults 
it  occurs  as  a  complication  of  gonorrhea  or  chancroids,  being  predis- 
posed to  by  phimosis  or  elongation  of  the  prepuce.  In  the  aged, 
formation  of  a  preputial  calculus  is  an  occasional  complication.^ 

Treatment. — In  cases  with  phimosis  or  adherent  prepuce,  dorsal 
incision  of  the  prepuce,  or  circumcision  should  be  done,  the  former 
being  preferable  in  gonorrheal  or  chancroidal  cases.  Inflammation 
may  be  reduced  before  and  after  operation  by  instillations  of  weak 
silver  nitrate  solution  between  glans  and  prepuce. 

Herpes  Progenitalis. — Herpetic  vesicles  sometimes  dcA-elop  on  the 
penis,  especially  on  the  mucous  layer  of  the  prepuce;  they  may  occur 
seemingly  spontaneously,  or  soon  after  coitus.  The  vesicles  resemble 
those  seen  in  cases  of  herpes  occurring  elsewhere  on  the  body.    The 


Fig.  973. — Paraphimosis  from  gonorrhea;  nine 
days'  duration.     Episcopal  Hospital. 


1  Under  the  name  of  "the  fourth  venereal  disease"  Corbiis  and  Harris  (1909) 
have  described  a  form  of  erosive  balanitis  due  to  symbiosis  of  a  spirochete  and  a 
vibrio.  The  spirochete  is  identical  with  that  of  Vincent's  angina,  found  in  the 
mouth,  and  the  infection  is  believed  to  be  conveyed  to  the  prepuce  and  glans  by 
unnatural  sexual  practices. 


CAh'ClXO.MA    OF    Till':   I' EN  IS 


1049 


iillVctioii  appciirs  first  ms  one  or  scNcnil  inimitc  reddish  pjijjiilcs  w  liicli 
turn  into  M-siclcs  in  the  conrsc  ol"  :i  IVw  hours.  Often  they  assume  a 
crescentic  outhne.  There  is  some  itehiuji;  and  tinji;nn<^,  and  after  the 
\esieles  rui)ture  contact  witli  the  urine  causes  hurnin;,'  pain.  Patients 
usually  are  subject  to  recurrinj;  attacks. 

Treatment.  The  u'cneral  health  sjiould  l)e  ^n\-en  attention,  and  any 
local  source  of  irritation  (j)himosis,  etc.)  should  be  a])pr()j)riately 
treated.  If  the  herpetic  \esicles  are  kept  clean  and  dry,  they  usually 
heal  within  a  few  days.  Astrin<j;ent  washes  {\  \)vv  cent.  suli)hate  of 
zinc,  or  acetate  of  lead)  should  be  applied  once  daily,  the  parts  beinj^ 
then  thorou<ihIy  dried,  and  powdered. 


Fig.  974. — \'onoreal  warts  from  phimosis.      Duration  seven  months.      No  voneri-al 
disease.     Episcopal  Hospital. 


Venereal  Warts  (Verrucae  Acuminatse). — This  affection  was  men- 
tioned at  p.  259.  It  has  no  necessary  connection  with  venereal  dis- 
ease. The  warts  usually  occur  in  persons  wdth  phimosis  or  redundant 
])repuce,  and  are  the  result  of  uncleanliness  (Fig.  974). 

Treatment. — In  mild  cases  it  is  sufficient  to  apply  caustics  (fuming 
nitric  acid)  every  day  or  so  until  the  warts  shrivel  up  and  drop  off; 
but  in  cases  complicated  by  phimosis  this  should  be  relieved  by 
appro])riate  means,  and  the  warts  should  be  excised  and  their  bases 
cauterized. 

Carcinoma. — Carcinoma  is  the  only  tumor  of  frequent  occurrence 
on  the  penis.  It  may  develop  in  an  old  venereal  scar;  is  predisposed 
to  by  the  existence  of  phimosis  or  balano-posthitis;i  but  often  no 
cause  is  evident.  It  presents  the  same  characteristics  as  carcinoma 
in  other  regions  of  the  body.  Usually  it  arises  on  the  glans  or  the 
prepuce.  The  squamous-celled  type  is  not  highly  malignant.  A  papil- 
lary form  is  more  usual,  is  much  more  malignant,  and  presents  irreg- 
ular projections,  resembling  venereal  warts  except  for  the  hardness 
of  their  bases  and  margins,  and  the  presence  of  ulceration,  which 
occurs  early.  The  inguinal  lymph  nodes  on  both  sides  are  involved 
early  in  the  papillary  variety,  not  until  later  in  the  squamous-celled 
type  of  carcinoma.     Invasion  of  the  pelvic  nodes  also  occurs. 

Treatment. — If  the  carcinoma  has  not  spread  beyond  the  glans, 
amputation  of  the  penis  is  sufficient;  but  if  the  corpora  cavernosa  have 

*  Leukoplakia  of  the  glans  is  recognized  as  a  pre-cancerous  condition. 


1050  SURGERY  OF  THE  MALE  GENITAL  ORGANS 

become  infiltrated  extirpation  of  the  entire  penis  is  necessary.  In  all 
cases  the  inguinal  lymph  nodes  should  be  excised;  usually  this  may 
be  done  at  the  same  time  as  the  operation  on  the  penis,  and  then  always 
as  the  first  step  of  the  operation;  but  if  the  tumor  is  very  septic,  it  is 
best  to  postpone  removal  of  the  inguinal  lymph  nodes  until  the  lower 
wound  has  healed. 

Amputation  of  the  Penis  involves  removal  only  of  the  phallic  portion 
of  the  penis:  a  rubber  tube  is  tied  around  the  base  of  the  organ,  to 
control  bleeding;  a  circular  incision  is  made  through  the  skin  well 
behind  the  seat  of  disease,  and  the  skin  is  allowed  to  retract.  The  cor- 
pora cavernosa  are  then  divided  at  the  base  of  the  skin-flap  and  closed 
transversely  by  sutures.  The  urethra  (with  the  corpus  spongiosum) 
is  dissected  free  for  a  centimeter  or  more  in  front  of  this  point,  and  is 
divided.  "The  urethra  is  then  slit  up  in  three  places,  one  below  and 
two  above;  the  three  square  fla})s  so  formed  are  then  turned  back  and 
their  corners  cut  off.  This  makes  three  small  triangular  flaps  which 
when  spread  out  form  one  large  triangle.  The  skin  is  then  sutured 
accurately  to  the  edges  of  this  triangle,  and  no  raw  surface  is  left" 
(G.  G.  Davis,  1897). 

Extirpation  of  the  Penis. — The  scrotum  is  slit  open  from  the  peno- 
scrotal juncture  to  the  perineum,  and  the  bulbous  urethra  is  isolated 
and  divided,  and  its  vesical  end  fixed  to  the  skin  of  the  perineum, 
being  split  on  its  under  surface  for  at  least  half  an  inch.  The  incision 
is  next  carried  around  the  base  of  the  penis,  the  suspensory  ligament  is 
divided,  the  crura  cut,  and  the  entire  penis  is  removed.  A  catheter 
is  left  in  the  bladder.  In  advanced  cases  it  is  necessary  to  remove  both 
testicles  and  spermatic  cords  as  far  as  the  internal  abdominal  ring, 
so  as  to  permit  complete  extirpation  of  the  inguinal  lymphatics. 


SURGERY    OF    THE    TESTICLES,   SCROTUM,    AND    SPERMATIC 

CORD. 

Congenital  Anomalies. — In  some  rare  cases  one  or  botli  testicles 
may  l)e  absent.  A  much  more  usual  anomaly  is  non-descent  of  the 
testicles,  on  one  or  both  sides,  called  respectively  monorchidism  and 
cryptorchidism.  The  affection  is  more  frequent  on  the  right.  The 
testicle  may  be  retained  in  the  abdominal  cavity  or  may  be  lodged 
in  the  inguinal  canal  or  at  the  external  ring.  Inguinal  hernia  often 
is  present  as  a  complication.  Rarely  the  testicle  is  misplaced,  being 
found  in  the  perineum  or  on  the  thigh.  In  most  cases  the  diagnosis 
of  non-descent  or  misplacement  is  readily  made  by  observing  the 
absence  of  the  testicle  from  the  scrotum,  and  its  presence  in  the  ingui- 
nal canal  or  elsewhere.  Sometimes  the  testicle  is  loandering,  slipping 
up  into  the  inguinal  canal  when  the  cremaster  contracts,  and  at  other 
times  remaining  in  the  scrotum  (Figs.  975  and  976). 

Treatment. — ^A  testicle  which  remains  in  the  inguinal  canal  or  at 
the  external  ring  is  constantly  exposed  to  injury;  one  which  comes  and 
goes  dilates  the  inguinal  canal  and  predisposes  to  the  development 


UNDESCENDED   TESTICLE 


1051 


of  hernia,  and  is  itself  liable  to  torsion  (see  below).  The  condition 
should  be  remedied  by  operation,  and  the  best  age  for  this  is  about 
six  years.  The  undescended  testicles,  according  to  Corner,  possess 
the  power  of  producing  spermatozoa  only  for  a  short  time,  usually 
from  the  age  of  twenty  to  twenty-two  years,  though  their  function 
of  internal  secretion  may  be  sufficient  to  ensure  the  acciuirenient 
of  secondary  sexual  characteristics  at  the  usual  age  of  puberty.  In 
any  case,  their  removal  is  contraindicated  unless  they  are  actually 
diseased.  The  main  therapeutic  indication  is  to  place  the  testicle 
in  a  situation  where  it  shall  not  l)e  exposed  to  injury.  If  possible  it 
should  be  brought  down  into  the  scrotum;  but  if  this  cannot  be  done, 
it  should  be  replaced  within  the  abdominal  cavity.'  The  operation 
is  begun  by  opening  the  inguinal  canal,  as  in  the  hernia  operation. 
The  testicle  is  exjHJsed,  and  a  hernial  sac  if  present  is  excised  and  the 
opening  in  the  i)arietal  peritoneum  is  closed.  If  the  cord  is  not  long 
enough  to  enable  the  testicle  to  be  replaced  in  the  scrotum,  it  often 


Fig.  975. — Wandering  testicle :  testicle 
now  in  inguinal  canal.  Age  fifteen  years. 
Episcopal  Hospital. 


Fiit.  97G. — Wandering  tcaticle:  testicle 
now  in  upper  part  of  scrotum.  Epis- 
copal Hospital. 


is  possible  to  lengthen  it  (Bevan,  190.'^)  by  careful  division  of  fibrous 
bands  and  freeing  the  structures  well  around  the  internal  ring,  by 
ligation  and  division  of  the  cremasteric  artery,  or  even  by  excision 
of  all  the  constituents  of  the  cord  except  the  vas  and  its  accompany- 
ing vessels;  the  latter  step  seldom  is  necessary,  but  according  to  Bevan 
sacrificing  the  spermatic  vessels  will  not  lead  to  gangrene  of  the  tes- 
ticle. ^Yhen  the  organ  has  been  brought  down  into  the  scrotum, 
it  should  be  fixed  by  sutures  to  the  median  scrotal  septum.  The 
cord  should  not  be  transplanted  as  in  the  Bassini  hernia  operation, 
but  should  be  treated  as  in  Ferguson's  method  (p.  792). 


1  The  supposition  that  a  mal-placed  testicle  is  more  prone  to  the  development 
of  malignant  tumors  than  the  normally  situated  organ,  is  cited  b}'  some  as  justifica- 
tion for  orchidectomy  (castration)  in  these  ca.ses.  But  this  supposition  rests  on 
inconclusive  facts;  and  even  if  it  were  true,  it  would  not  be  the  mal-position  which 
created  the  predisposition  to  malignant  disease,  but  some  developmental  defect 
in  the  organ  itseK  and  the  occurrence  of  mahgnant  changes  would  be  no  more  fre- 
quent if  the  testicle  were  retained  in  the  abdomen  than  if  it  were  replaced  in  the 
scrotum. 


1052 


SURGERY  OF  THE  MALE  GENITAL  ORGANS, 


Torsion  of  the  Testicle,  generally  traumatic  in  origin  (straining 
efi'orts,  contortions  of  the  body,  etc.),  occurs  usually  in  children  with 
unduly  mo\'able  testicles.  In  most  cases  the  tunica  vaginalis  extends 
up  to  the  internal  ring,  and  congenital  hydrocele  (p.  105S)  may  be 
present.  The  symptoms  are  acute,  sickening  ])ain  in  the  inguinal  canal 
or  scrotum  according  to  the  site  of  the  testicle;  the  testicle  becomes 
a  little  swollen,  and  is  extremely  tender.  The  diagnosis  must  be  made 
from  strangulated  inguinal  hernia  and  from  inflamed  hydrocele  of 
the  cord.  In  these  conditions  a  normally  placed  and  symptomless 
testicle  usually  is  present.  Treatment  is  by  operation,  which  consists 
in  uncoiling  the  twist  and  fixing  the  testicle  in  normal  position  by 
means  of  sutures;  or  in  castration  if  gangrene  of  the  testicle  has 
occurred. 

Inflammation  of  the  Testicle. — Orchitis  implies  inflammation  of 
the   testis   proper;   while   inflammation   of   the   ejjididymis   is   called 

epididymitis.  In  most  cases 
both  component  parts  of  the 
testicle  are  affected  (epidi- 
dymo-orchitis) ,  but  almost 
in\arial)ly  one  or  the  other 
affection  dominates  the  clin- 
ical picture.  Apart  from 
traimia,  which  is  not  a  very 
frequent  cause,  the  disease 
is  oftenest  due  to  infection 
carried  by  the  blood-stream 
(orchitis)  or  extending  from 
the  urethra  through  the  vas 
deferens  (epididymitis).  Or- 
chitis is  much  more  fre- 
quent in  boys  than  in  adults, 
and  occurs  as  a  complication 
of  mumps  (Fig.  977),  tonsil- 
litis, influenza,  etc.  The  at- 
tack lasts  about  four  days. 
Usually  the  right  testis  is 
affected,  but  occasionally  both  sides  are  attacked  one  after  the  other. 
Some  atrophy  may  occur  subsequently.  Suppuration  often  occurs  in 
cases  complicating  typhoid  fever.  Epididymitis  usually  is  a  compli- 
cation or  sequel  of  gonorrhea,  occurring  from  the  third  to  the  sixth 
week  of  the  disease.  Sometimes  it  occurs  after  the  passing  of  a  sound 
or  catheter,  especially  in  cases  of  prostatic  enlargement.  The  left  side 
is  affected  oftener  than  the  right,  but  both  sides  may  be  involved 
in  turn. 

Symptoms. — Symptoms  of  orchitis  and  epididymitis  are  of  rather 
sudden  onset,  but  prodromes  (malaise,  headache,  nausea,  creepiness, 
and  chilliness)  may  occur.  The  earliest  symptoms  may  be  referred 
to  the  abdomen,  and  may  be  mistaken  for  those  of  appendicitis. 


Fig.  977. — Urchins  I'ullowiag  muiiipb.  Age 
fourteen  years.  Mumps  one  week  ago,  followed 
first  by  left  orchitis,  which  subsided;  then  by 
right  orchitis,  which  has  lasted  for  three  days. 
Episcopal  Hospital. 


ORCHITIS   AM)  J'JJ'IDIUYMJTIS  1053 

The  tosticlr  hecoincs  acutely  j)aiiifiil,  cxccssixcly  tender,  and  swollen; 
most  of  the  swellinj^  is  due  to  inflammatory  ell'usion  into  the  tunica 
vaj^jinalis  (artitc  hi/drorrlc).  The  scrotum  may  become  red  and  edema- 
tous. The  temperature  sometimes  is  hij^h,  and  the  patient  may 
appear  very  ill,  at  least  for  a  time.  If  the  patient  keeps  on  his  feet, 
and  particularly  if  the  testicle  is  allowed  to  hanj,'  unsupported,  all 
the  symptoms  are  agi^ravatcd,  and  there  may  he  drafitginj;  abdominal 
pains.  The  diagnosis  between  orchitis  and  epididymitis  may  be  made 
by  noting  the  history  of  the  case  and  the  probable  cause  of  the  scrotal 
swelling;  by  observing  that  in  epididymitis  the  swelling  begins  in  the 
globus  minor,  si)reads  to  the  globus  major,  and  that  when  the  entire 
epididymis  is  ati'ected  it  forms  a  "boat-shaped"  enlargement  on  the 
outer  and  back  part  of  the  testis.  Most  of  the  scrotal  enlargement, 
as  already  remarked,  is  caused  l)y  acute  hydrocele  of  the  tunica  vagi- 
nalis. In  orchitis  the  smooth  globular  form  of  the  testicle  is  felt,  and 
the  e])i(li(lymis  is  not  palpably  enlarged. 

Treatment. — The  patient  should  be  put  to  bed,  and  the  scn^tum 
elevated.  Heat,  especially  in  the  form  of  a  flaxseed  poultice,  is  better 
than  cold  as  a  local  application.  If  injections  have  been  in  use,  for 
gonorrhea,  they  should  be  stopped.  Some  urinary  antiseptic  should 
be  given.  Puncture  of  the  tense  tunica  albuginea  in  one  or  several 
places,  with  a  fine  tenotome,  is  the  most  efficient  way  of  relieving 
pain.  No  anesthetic  is  required.  The  scrotum  is  painted  with  2  per 
cent,  iodin  solution,  and  is  drawn  tensely  over  the  testicle,  and  the 
puncture  is  made  at  the  seat  of  greatest  swelling.  This  plan  is  said 
to  have  been  suggested  by  Petit,  and  widely  employed  by  Vidal  de 
Cassis,  and  by  H.  Smith,  during  the  last  century.  As  an  open  oper- 
ation the  method  has  been  recently  revived  by  Bazy,  Belfield,  and 
Hagner;  for  this,  a  general  anesthetic  is  advisable:  the  tunica  vaginalis 
is  incised,  its  contents  evacuated,  and  the  inflamed  epididymis  is  punc- 
tured in  one  or  several  places;  the  scrotal  wound  is  then  packed  with 
gauze.  If  no  operation  is  done  acute  symptoms  begin  to  subside  in 
four  or  five  days ;  then  sorbef acient  ointments,  especially  those  contain- 
ing guaiacol  and  ichthyol,  should  be  applied,  and  when  only  a  painless 
induration  remains  resolution  may  be  favored  by  strapping  the  testicle 
with  adhesive  plaster  or  with  a  broad  strip  of  rubber  tissue.  In  the  most 
acute  cases  of  gonorrheal  epididymitis  suppuration  may  occur,  requir- 
ing incision  and  drainage  of  an  abscess;  occasionally  castration  is 
reciuired.  In  almost  all  cases  cicatricial  changes  occur  in  the  body 
or  globus  minor  of  the  epididymis,  which  prevent  discharge  of  semen 
into  the  vas  deferens;  and  if  both  sides  have  been  affected  the  patient 
may  be  rendered  sterile.  To  overcome  this  condition,  which  is  said 
to  occur  in  about  40  per  cent,  of  cases  of  bilateral  epididymitis,  Edward 
Martin  (1902)  has  practised  with  success  an  anastomosis  between  the 
globus  major  and  the  vas  deferens  (epididymo-vasostomy).  Cases  of 
recurrent  epididi/mitis  often  are  caused  by  infection  from  the  seminal 
vesicles,  and  can  be  cured  only  by  proper  treatment  of  this  focus  of 
infection. 


1054  SURGERY  OF   THE  MALE  GENITAL  ORGANS 

Neuralgia  of  the  Testicle. — Under  this  name  is  described  a  condi- 
tion in  which  the  testicle,  usually  the  left,  is  persistently  tender  and 
afflicted  with  lancinating  pains.  This  condition  must  be  distinguished 
from  referred  pain  due  to  lesions  elsewhere,  notably  renal  calculus 
and  varicocele.  If  no  cause  for  referred  pain  exists,  and  a  history  of 
epididymitis,  or  orchitis  is  obtained,  it  is  probable  that  the  neuralgia 
is  due  to  compression  of  the  testicle  by  sclerosis  and  contraction  of 
the  tunica  vaginalis  or  albuginea;  under  such  circumstances  continu- 
ance of  palliative  measures  (use  of  a  suspensory,  hot  and  cold  douches, 
occasional  passage  of  a  cold  sound,  or  instillations  of  argyrol  into  the 
deep  urethra,  etc.)  probably  will  prove  useless,  and  it  is  best  to  expose 
the  testicle  and  excise  the  tunica  vaginalis. 

Semino-vesiculitis  or  Spermato-cystitis. — This  may  be  acute  or 
chronic.  The  acute  form  almost  invariably  occurs  as  a  complication 
of  gonorrhea.  Chronic  semino-vesiculitis  usually  is  a" sequel  of  the 
acute  form,  but  the  condition  may  be  chronic  from  the  start  and  may 
be  due  not  to  gonorrhea  but  to  non-gonococcic  posterior  urethritis  or 
prostatitis.  In  most  cases  only  one  vesicle  is  affected  at  first,  but 
the  second  rarely  escapes  eventual  infection.  In  the  acute  form  the 
vesicle  is  distenderl  with  purulent  exudate,  but  inflammatory  infil- 
tration of  surrounding  tissues  may  occur  to  such  a  degree  that  the 
vesicles  cannot  be  recognized  by  palpation  through  the  rectum.  The 
symptoms  of  the  acute  form  are  pain  in  the  perineum  or  rectum, 
especially  after  defecation  or  seminal  ejaculation.  The  semen  often  is 
blood-stained,  and  may  be  colored  blue  from  the  admixture  of  indigo. 
Sexual  excitability  is  pronounced,  and  frequent  and  painful  erections 
are  characteristic.  In  the  chronic  form  the  symptoms  are  those  of 
the  gleet  fp.  1011);  recurrent  attacks  of  epididymitis  often  occur. 

Treatment. — In  acuie  semino-vesiciilifis  the  patient  should  be  con- 
fined to  bed,  and  all  local  treatment  of  the  urethral  condition  should 
be  discontinued.  A  hot  water  bag  may  be  applied  to  the  perineum, 
or  hot  rectal  injections  may  be  given  if  they  lessen  discomfort.  Urinary 
antiseptics  should  be  given,  and  the  bowels  should  be  opened  by  a 
laxative.  If  pain  is  excessive,  and  particularly  if  constitutional  symp- 
toms exist,  the  occurrence  of  suppuration  should  be  suspected:  the 
patient  then  should  be  anesthetized  and  the  rectum  explored;  if  any 
signs  indicating  suppuration  are  found,  the  vesicle  should  be  exposed 
through  the  perineum  (by  the  method  advised  for  perineal  prosta- 
tectomy), opened  and  drained.  The  treatment  of  chronic  semino- 
vesiculitis  has  already  been  considered  in  connection  with  chronic 
urethritis.  In  cases  of  recurrent  epididymitis,  Belfield  opens  the  vas 
deferens  below  the  external  abdominal  ring  and  irrigates  the  seminal 
vesicle  by  injecting  not  more  than  2  c.c.  of  the  irrigating  fluid.  As 
noted  at  p.  472,  Fuller  drains  the  seminal  vesicles  through  the 
perineum  in  cases  of  gonococcic  arthritis. 

Tuberculosis  of  the  Testicle. — This  probably  is  caused  in  inost 
cases  by  hematogenous  infection.  Keyes,  however,  maintains  that 
it  is  always  secondary  to  tuberculosis  of  the  prostate  and  seminal 


TUBERCULOSIS  OF   THE   TESTICLE 


1055 


vesicles.  The  lesion  in  the  testicle  begins  in  the  <,'l()l)us  major  of  the 
epididymis^  and  invades  the  testis  seconchirily.  The  ])ati('nts  nsnally 
are  between  twenty  and  thirty  years 
of  age,  and  as  a  rule  only  one  tes- 
ticle is  afl'ecte<l  at  first,  but  exten- 
sion to  the  other  side  is  freciuent, 
probably  by  way  of  the  seminal  vesi- 
cles and  ejaculatory  ducts  through 
the  vas  deferens. 

Symptoms. — The  onset  usually  is 
insidious,  and  the  ])atient  may  be 
scarcely  aware  of  his  condition  until 
he  discovers  by  accident  a  hard 
nodule  in  the  epididymis,  or  until 
supi)uration  has  occurred  with 
fistulization  of  the  scrotum.  In 
the  rare  cases  with  acute  onset 
the  condition  at  first  somewhat 
resembles  gonorrheal  epididymitis; 
but  unlike  this  aHection  it  does  not 
subside  in  the  course  of  a  week 
or  two.  In  most  cases  the  clini- 
cal diagnosis  must  be  considered 
uncertain  until    areas  of    softening 

have  formed;  usually  this  is  quickly  followed  by  implication  of  the 
skin  of  the  scrotum,  which  becomes  adherent  to  the  testicle   (Fig. 

978) ;  then  the  cold  abscess 
ruptures  and  cheesy  pus  is 
constantly  discharged  from  the 
fistula  (Fig.  979) .  At  this  stage 
the  diagnosis  may  be  confirmed 
bv    finding  tubercle  bacilli    in 


Fig.  978. — Tuberculosis  of  both  tes- 
ticles, duration  four  months;  age  nine- 
teen years.  Right  testicle  adherent  to 
skin,  and  abscess  palpable.  Both 
seminal  vesicles  enlarged  and  nodular. 
Episcopal  Hospital. 


the  discharge;  at  earlier  stages 
focal  reaction  to  a  tuberculin 
test  may  be  relied  on. 

Treatment. — There  is  much 
dispute  among  surgeons  as  to 
the  proper  treatment  of  these 
patients.  Some  advise  imme- 
diate castration  in  all  cases; 
others  condemn  all  operative 
interference  and  trust  entirely 
to  hygienic  measures  and  vaccine  therapy.  ^ly  own  feeling  is  that 
so  long  as  suppuration  and  fistulization  do  not  occur  there  is  no  need 
to  remove  the  testicle.  A  nodule  in  the  epididymis  may  remain 
unchanged  for  years  provided  excellent  hygienic  life  conditions  are 


Fig.  979. — Tuberculosis  of  left  testicle, 
duration  two  years;  age  thirty-three  years. 
Operation  for  left  hydrocele  eighteen  months 
ago;  fistulte  in  scrotum  for  last  six  months. 
(See  Fig.  980.)     Episcopal  Hospital. 


In  gonococcic  epididymitis  the  globus  minor  is  attacked  before  the  globus  major. 


1056 


SURGERY  OF   THE  MALE  GEXITAL  ORGANS 


present,  as  has  been  shown  l)^  Watson  and  Cunningham.  Under  such 
circumstances  (and  if  tuberculous  lesions  exist  elsewhere  in  the  body, 
even  if  the  local  lesion  is  advanced)  minor  operative  measures  may  be 
of  benefit  to  the  local  condition  and  may  promote  the  patient's  com- 
fort. Epididymectomy  sometimes  is 
done,  leaving  the  testis  intact,  with 
or  without  anastomosis  between  it 
and  the  vas  deferens.  According  to 
Barney  (1911)  the  semen  is  sterile  in 
So  per  cent,  of  patients  even  before 
epididymectomy.  A  cold  abscess  may 
be  treated  on  the  same  principles 
recommended  when  dealing  with  cold 
abscesses  in  association  with  bone 
disease.  But  when  fistulization  has 
occurred,  and  particularly  if  secondary 
infection  is  present,  I  feel  quite  sure 
it  is  best,  especially  in  the  average 
hospital  patient,  to  remove  the  testicle 
and  spermatic  cord  as  far  as  the 
internal  ring.  The  operation  is  de- 
scribed below.  If  only  one  testicle  is 
diseased  and  is  removed,  only  about 
9  per  cent,  of  patients  die  of  genito- 
urinary tuberculosis,  the  other  testicle 
becomes  involved  subsequently  only 
in  about  26  per  cent.,  and  cure  fol- 
lows in  about  45  per  cent,  of  patients; 
if  double  castration  is  necessary,  15  per 
cent,  of  patients  die  within  the  first 
three  years  after  operation,  but  56  per 
cent,  are  permanently  cured  (Haas). 
Castration  or  Orchidectomy. — Open  the  inguinal  canal,  as  in  the 
operation  for  hernia.  Transfix  and  ligate  the  spermatic  cord  at  the 
internal  abdominal  ring.  Cut  the  cord  below  the  ligature  and  turn 
it  down  over  the  scrotum  with  its  annexed  fatty  tissue  and  lymph 
nodes.  Close  the  inguinal  wound  (except  at  the  lower  angle  where 
the  cord  emerges)  as  in  the  operation  for  hernia,  and  cover  it  with 
sterile  gauze.  Then  proceed  to  remove  the  testicle  in  one  mass  with 
the  adherent  scrotum,  by  extending  the  original  incision  downward, 
cutting  wide  of  all  infiltrated  tissue.  In  this  way  the  inguinal  wound 
runs  no  risk  of  being  infected,  since  it  is  closed  before  the  suppurating 
scrotal  tissues  are  attacked,  and  all  the  diseased  tissue  is  removed  in 
one  mass.  Usually  it  is  well  to  leave  a  small  drain  in  the  scrotal  end 
of  the  incision  for  a  couple  of  days. 

Syphilis  of  the  Testicle. — Sarcocele.' — Sarcocele  is  a  manifestation 
of  the  third  stage  of  syphilis.     The  lesion  almost  always  is  in  the 

1  This  is  an  old  term  still  in  use,  signifying  a  fleshy  or  solid  tumor;  by  long  usage 
it  is  applied  exclusivel}'  to  enlargements  of  the  testicle. 


Fig.  980. — Specimen  removed  by 
castration  from  the  patient  shown  in 
Fig.  979:  testicle  and  adherent  skin 
of  scrotum,  with  spermatic  cord  and 
inguinal  lymph  nodes  in  one  mass. 
Episcopal  Hospital. 


SARCOCELE 


1  ().")( 


Fig.  981. — Scars  frf)ni  doiihlo  orfhidoctoniy  for 
tuberculous  sarcocclc.  Age  forty-six  years.  Epis- 
copal Hospital. 


testis,  not  in  tlio  (•i)i(li(lymis;  the  most  frequent  form,  elinically,  is  a 
gummatous  deposit  in  one  or  several  si)ots.  I'alliologieaily  a  diU'use 
sclerosis  of  the  tunica  alhuginea  and  septa  of  the  testis  is  a  very  fre- 
quent lesion,  l)ut  it  is  seldom  reco<,niized  c-linicall\'.  In  most  cases 
of  the  jiinnmatous  form 
of  the  disease  only  one 
testis  is  involved;  soften- 
ing of  the  gumma  with 
ulceration  of  the  skin 
scarcely  ever  occurs.  The 
affection  is  extremely  in- 
dolent. The  testicle  grows 
slowly  and  never  reaches  a 
\ery  large  size;  it  presents 
smooth,  rounded  nodules 
almost  of  woody  hardness 
and  not  at  all  tender.  If 
the  epididymis  is  involved 
the  testis  feels  like  a 
stone  lying  in  a  clam  shell, 
the  sharp  edges  of  the 
hardened  epididymis  em- 
bracing the  testis  (Keyes). 

Frequently  a  hydrocele  of  the  tunica  vaginalis  is  present.  The  only 
subjective  symptoms  are  those  due  to  the  increased  w^eight  of  the 
organ.  A  history  of  syphilis  usually  can  be  obtained ;  the  Was.sermann 
test  will  be  positive ;  and  antisyphilitic  treatment  will  prove  rapidly 
curative.     The  diagnosis  must  be  made  from  tuberculosis  and  from 

tumors  of  the  testicle.  In  the 
former  the  epididymis  is  af- 
fected, and  invasion  and  fistuli- 
zation  of  the  skin  are  frequent. 
In  the  latter,  most  of  which 
are  instances  of  malignant 
disease,  the  testicle  grows 
rapidly,  attains  a  much  greater 
size  than  in  syphilis,  there  is 
more  pain  and  discomfort, 
and  invasion  of  the  skin  is 
frequent,  with  the  protrusion 
of  a  fungus  growth. 

Treatment. — In  every  case  of 
sarcocele,  where  the  diagnosis 
is  doubtful,  it  is  well  to  try 
antisyphilitic  treatment  before  any  operation  is  recommended.  If 
the  disease  is  syphilitic,  mixed  treatment  will  be  quickly  effectual. 

Neoplasms  of  the  Testicle  are  not  very  rare,  except  benign  tumors. 
]\Iost  of  the  tumors  are  extremely  malignant,  and  are  classed  loosely 
67 


Fig.  982. — Sarcoma  of  right  testicle.  Age 
seventy-four  years,  duration  five  months. 
Diagnosis  made  after  tapping  hydrocele  (four 
ounces  of  bloody  fluid),  which  permitted  pal- 
pation of  hard  nodular  growths.  Episcopal 
Hospital. 


1058 


SURGERY  OF   THE  MALE  GENITAL  ORGANS 


as  sarcomas.  Chevassu  (1910),  in  a  careful  study  of  100  cases,  found 
carcinoma  (seminoma)  in  47,  true  sarcoma  in  3,  and  mixed  tumors  in 
50  cases.  Such  tumors  may  occur  at  any  age,  but  are  most  frequent 
in  middle  life.  Growth  is  rapid  (weeks),  and  the  tumor  may  become 
several  times  as  large  as  the  normal  testicle.  In  most  cases  hydrocele 
of  the  tunica  vaginalis  develops,  and  its  contained  fluid  usually  is 
blood-stained  (Fig.  982) :  if  there  is  no  history  of  injury  the  presence 
of  blood  in  hydrocele  fluid  always  suggests  malignancy.  Extension 
occurs  early  along  the  spermatic  cord,  and  to  the  lumbo-aortic 
lymph  nodes,  and  especially  to  a  lymph  node  at  the  bifurcation  of 
the  common  iliac  vein. 

Treatment. — By  the  ordinary  method  of  castration,  as  described 
in  connection  with  tuberculosis  of  the  testicle,  surgery  succeeds  in 
saving  about  20  per  cent,  of  patients.^  Radical  oi^eration  implies  re- 
moval of  the  tumor  in  one  mass  with  its  anatomically  related  lymph 
nodes.  Chevassu  has  devised  a  technique  by  which  the  lumbo-aortic 
nodes  may  be  reached:  the  incision  passes  along  the  inguinal  canal 
and  up  the  abdominal  wall  outside  the  semilunar  line  as  far  as  the 
false  ribs,  and  if  necessary  is  extended  forward  along  the  costal  border. 
The  parietal  peritoneum  is  dissected  inward,  without  opening  the 
peritoneal  cavity,  and  when  the  perirenal  fascia  is  reached  its  anterior 
layer  is  incised,  and  the  dissection  continued  in  front  of  the  kidney, 

until  the  renal  vessels  and 
aorta  are  exposed.  In  1910 
Chevassu  collected  records 
of  11  such  operations,  with 
no  immediate  mortality;  in 
8  the  operation  was  carried 
to  a  successful  conclusion, 
but  in  3  others  had  to  be 
abandoned  (inoperable) . 

Hydrocele. — This  is  a  col- 
lection of  serous  fluid  in  the 
tunica  vaginalis. 

In  congenital  hydrocele 
(Fig.  983)  there  is  a  com- 
munication between  the  tu- 
nica vaginalis  and  the  peri- 
toneal cavity,  Usuall\'  the  orifice  of  communication  is  too  small  for 
the  development  of  a  hernia.  The  condition  is  noted  first  in  infancy, 
but  may  persist  until  adult  life,  even  without  the  development  of  a 
hernia.  When  the  scrotum  is  elevated  the  fluid  disappears  within  the 
abdominal  cavity,  usually  very  slowly,  and  as  slowly  reappears  when 
the  erect  posture  is  resumed.  Treatment  is  the  same  as  for  inguinal 
hernia  in  infants. 

^  Out  of  100  patients  with  malignant  disease  of  the  testicle  treated  by  the  ordinary 
method  of  castration,  Chevassu  found  81  died  in  less  than  four  years,  while  19 
survived  in  good  health  for  periods  varying  from  four  to  ten  years  after  operation. 


Fig.  9!S3. — Congenital  hydrocele  (left).    Age  five 
months.     Children's  Hospital. 


HYDROCELE 


1059 


Fig.  984. — Hydrocele  of  the  right  tunica 
vaginalis,  in  a  child  of  three  years.  Chil- 
dren's Hospital. 


Acquired  Hydrocele  of  tlie  tunica  vaginalis  is  seen  oftenest  in  cliild- 
liood  and  in  middle  adult  life  (Figs.  i)S4  and  085).  The  pathogenesis 
of  the  lesion  is  uncertain,  but  the  fluid  probably  is  in  the  nature  of  an 
exudate,  due  to  trauma  or  some  form  of  infection  of  low  grade.  As 
already  mentioned,  gonorrheal  epididymitis  and  most  other  infections 
of  the  testicle  are  accompanied 
by  the  development  of  acute  hy- 
drocele, and  such  a  lesion  may 
lay  the  foundation  for  the  sub- 
sequent pathological  change  in 
the  serous  membrane  which 
leads  to  chronic  serous  effusion. 
It  is  possible  that  many  adult 
hydroceles  are  unrecognized 
manifestations  of  tuberculosis 
(Fig.  979)  or  syphilis.  In  some 
cases  rice  bodies  are  found,  and 
the  sac  may  become  calcareous. 
Most  of  the  adults  affected  are 
arteriosclerotic. 

Symjjfoms. — The  swelling  commences  at  the  bottom  of  the  scrotum, 
and  gradually  increases  in  size.  At  first  it  is  soft  and  fluctuating, 
but  eventually  may  become  very  tense  and  hard.  The  patient  has 
little  or  no  discomfort  except  from  the  size  and  weight  of  the  swelling. 
Usually  relief  is  sought  before  a  very  great  size  is  attained.  Rarely 
the  sac  extends  into  the  inguinal  canal,  and  from  the  existence  of  con- 
strictions (similar  to  those 
encountered  in  some  cases  of 
inguinal  hernia — see  p.  781) 
an  hour-glass  or  bilocular  hy- 
drocele may  result  (Fig.  986). 
The  same  appearance  may  be 
caused  by  the  coexistence  of 
a  vaginal  hydrocele  and  a 
hydrocele  of  the  cord. 

The  diagnosis  is  made  from 
the  history  of  the  case,  and 
from  observing  that  most  hy- 
droceles are  translucent  when 
examined  by  transmitted  light; 
old  hydroceles,  with  thickened 
walls,  and  those  into  which 
hemorrhage  has  occurred, 
from  hernia   was   considered 


Fig.  985. — Hydrocele  of  tunica  vaginalis. 
Age  fifty-two  years;  duration  nine  years; 
tapped  eight  times.  One  quart  withdrawn 
after  making  photograph.    Episcopal  Hospital. 


however,   are   opaque.    The  diagnosis 
at  p.  783. 

The  best  treatment  is  by  operation;  but  in  adults  who  refuse  operation 
or  in  whom  operation  is  contraindicated  for  any  reason,  it  is  sufficient 
to  withdraw  the  fluid  from  time  to  time  by  tapping  the  hydrocele. 


lOGO 


SURGERY  OF   THE  MALE  GENITAL  ORGANS 


Fig.  9SG. — Bilocular  hydrocele. 
Age  twenty-three  years;  duration 
since  infancy.  (Dr.  C.  F.  Mitchell's 
case.)     Pennsylvania  Hospital. 


The  testicle  almost  always  is  at  the  back  part  of  the  swelling,  hut  its 
position  should  be  ascertainerl  by  palpation  and  by  examination  with 
transmitted  light.  The  tumor  is  then  grasped  in  the  left  hand,  and 
the  skin  is  drawn  tightly  over  it,  when  with  a  quick  thrust  a  trocar 

and  cannula  are  pushed  into  the  most 
prominent  part  of  the  swelling,  avoid- 
ing large  veins.  The  trocar  is  then 
withdrawn  and  the  contents  of  the 
hydrocele  allowed  to  flow.  When  all 
the  fluid  has  been  evacuated  the  can- 
nula is  withdrawn  and  the  puncture  is 
sealed  with  cotton  and  collodion.  No 
anesthetic  is  required  and  the  patient 
need  not  be  confined  to  bed.  He  should 
wear  a  close-fitting  suspensory  in  an 
endeavor  to  prevent  too  rapid  re-ac- 
cumulation of  the  fluid.  It  is  well  to 
examine  the  testicle  carefully  after  the 
hydrocele  fluid  has  been  evacuated, 
as  in  many  cases  it  is  found  diseased. 
Some  surgeons  recommend  the  injec- 
tion into  the  emptied  sac  of  some 
irritating  or  caustic  fluid  in  the  hope 
of  causing  obliteration  of  the  cavity;  but  the  alleged  advantages  of 
this  practice  do  not  compensate  for  the  dangers  of  uncontrollable 
inflammation  and  excessive  pain.  In  most  cases  in  which  simple  tap- 
ping is  done,  re-accumulation  of  the  fluid  occurs  at  progressively 
shorter  intervals. 

Oyerution. — In  most  cases,  especially  in  children  and  young  adults, 
it  is  best  to  resort  to  operation.  The  incision  should  be  made  just 
below  the  external  abdominal  ring,  not  in  the  scrotum,  as  this  is  diffi- 
cult to  sterilize.  The  operation  most  often  done,  known  by  the  name 
of  Jaboulay  (1895),  consists  in  evacuating  the  contents  of  the  sac  by 
incision,  and  everting  the  icalls  of  the  tunica  vaginalis  around  the  testicle 
so  that  the  serous  surface  of  the  tunica  vaginalis  lies  against  the  sub- 
cutaneous tissues.  If  the  incision  in  the  tunica  vaginalis  is  made  just 
large  enough  to  push  the  testicle  through,  no  sutures  are  required  to 
hold  the  everted  tunica  vaginalis  in  place;  this  is  known  as  the  "bottle 
operation."  I  have  had  one  recurrence  after  this  operation  in  a  child, 
and  know  of  others;  and,  therefore,  prefer  excision  of  the  sac  (von 
Bergmann).  In  cases  with  much  thickening  of  the  tunica  vaginalis 
it  is  well  to  scrape  the  testicular  portion  of  the  tunica  vaginalis  with 
Volkmann's  sharp  spoon,  as  it  cannot  be  removed  with  the  knife 
Avithout  damage  to  the  testicle. 

Hydrocele  of  the  Cord  is  a  collection  of  serous  fluid  in  an  unoblit- 
erated  portion  of  the  funicular  process  of  peritoneum.  If  the  sac 
communicates  with  the  peritoneal  cavity,  the  condition  is  known  as 
funicular  hydrocele;  if  the  sac  is  closed  at  both  ends,  it  is  an  encysted 


VARICOCELE 


1001 


Fk;.  987. — -Encysted  hydrocele  of 
the  cord.  Age  two  and  a  half  years. 
Children's  Hospital. 


In/(lnirrlr  nf  the  cord  ( Fij;.  i)N7).     Ili/drorcle  of  ffir  c(in(il  of  Xurl:  is  tlie 
c'orrcspondiiijf  coiiditioii  in  the  female  sex.    If  iiiflimiiiiatioM  of  the  sac 
occurs  from  any  cause,  and  no  accurate  history  can  he  ol)tainc(l,  the 
condition  may   he  reachlx'  mistaken 
for  stran<iulated  hernia.       Trcafnwnf 
of  hydrocele  of  the  cord  consists  in 
excision  of  the  sac. 

Spermatocele.  —  Spermatocele, 
known  also  as  encysted  hydrocele  of  the 
tunica  vaginalis,  is  a  cyst  whicli 
de\elops  aliout  the  globus  major 
of  the  epididymis  and  contains 
spermatic  fluid.  Its  pathogenesis  is 
disputed.  It  occurs  oftenest  in 
young  adults,  and  forms  a  slowly 
growing  but  tense  cystic  tumor 
at  the  upper  and  back  part  of  the 
testicle.  It  may  project  into  the 
tunica  vaginalis  or  grow  behind  it.  The  diagnosis  often  is  not  madt^ 
until  operation  is  done.     Proper  treatment   is  excision  of  the   sac. 

Hematocele. — A  collection  of  blood  in  the  tunica  vaginalis  may 
result  from  injury  or  disease;  there  may  or  may  not  have  been  a  pre- 
existing hydrocele.  In  many  cases  seemingly  of  spontaneous  origin, 
hematocele  is  symptomatic  of  malignant  disease  of  the  testicle.  The 
physical  signs  are  the  same  as  those  of  vaginal  hydrocele,  except  that 
the  swelling  is  opaque  to  transmitted  light. 

Treatment. — In  acute  traumatic  cases  the  blood  should  be  with- 
drawn by  tapping.  In  other  cases  the  treatment  is  that  of  the 
underlying  cause  (hydrocele,  sarcocele). 

Varicocele. — A  varicose  condition  of  the  veins  of  the  spermatic 
cord  (the  pampinniform  plexus)  occurs  in  about  10  per  cent,  of  males, 
usually  commencing  about  the  age  of  puberty.  In  almost  all  cases 
the  left  side  is  affected,  occasionally  both  sides,  very  seldom  the  right 
alone.  This  predilection  for  the  left  side  is  attributed  (1)  to  the  pres- 
sure of  the  sigmoid  on  the  spermatic  vein;  (2)  to  the  fact  that  the  left 
spermatic  vein  enters  the  left  renal  at  a  right  angle,  while  the  right 
spermatic  enters  the  vena  cava  obliquely;  (3)  to  the  absence  of  valves 
on  the  left  side;  (4)  to  the  lower  position  of  the  left  testicle  in  the 
scrotum;  and  (5)  to  the  habit  most  men  have  of  "dressing  left." 
Seldom  or  never  can  any  exciting  cause  be  found.  The  rather  rapid 
onset  of  a  varicocele  usually  is  symptomatic  of  some  abdominal 
neoplasm  obstructing  the  venous  circulation. 

Symptoms. — Symptoms  may  be  entirely  absent  even  in  cases  where 
the  varicocele  is  very  large.  Often,  however,  the  patient  complains 
of  vague  dragging  pains  and  discomfort  in  the  left  side  of  the  scrotum, 
and  there  may  be  occasional  lancinating  pains  in  the  testicle  and  along 
the  cord.  Atrophy  of  the  testicle  is  mentioned  as  a  possible  sequel, 
but  I  never  observed  it.    In  rare  cases  the  patient  may  be  "neuras- 


1062 


SURGERY  OF   THE  MALE  GENITAL  ORGANS 


thenic."  Examination  shows  a  relaxed  state  of  the  scrotum,  with 
the  left  testicle  hanging  very  low,  and  above  it,  extending  up  to  the 
inguinal  canal,  a  soft  mass  of  dilated  veins  which  feel  like  a  bunch 
of  earthworms  (Fig.  988).  These  veins  may  be  emptied  by  having 
the  patient  lie  down  and  elevating  the  scrotum;  they  will  become 
distended  again  when  he  stands  up,  even  if  pressure  is  made  over  the 
inguinal  canal. 


Fig.  988. — Varicocele,  age  thirty-six  years.     Episcopal  Hospital. 

Treatment. — Treatment  seldom  is  required.  There  is  nothing  serious 
in  the  condition  and  it  often  disappears  spontaneously  later  in  life. 
If  the  patient  is  uncomfortable  he  will  feel  better  for  wearing  a  sus- 
pensory bandage,  particularly  in  warm  weather.  Cold  douches 
sometimes  are  soothing.  If  marked  discomfort  persists,  the  varicocele 
is  easily  cured  by  a  simple  operation.  An  incision  is  made  just  below 
the  external  abdominal  ring,  and  the  cord  is  brought  out  of  the  wound. 
The  dilated  veins  are  separated  from  the  vas  deferens  and  its  accom- 
panying vessels,  and  the  varicose  veins  are  ligated  close  to  the  external 
ring,  and  again  about  two  inches  lower.  The  ends  of  these  ligatures 
are  left  long,  and  after  the  section  of  veins  lying  between  the  ligatures 
has  been  removed,  the  ligature  on  the  proximal  end  is  tied  to  that  on 
the  scrotal  end  of  the  cord,  thus  shortening  the  cord  and  elevating 
the  testicle.  The  wound  is  closed  without  drainage  (careful  hemo- 
stasis),  and  the  patient  stays  in  bed  a  week  or  ten  days. 

Elephantiasis. — Elephantiasis  occurs  oftenest  in  the  scrotum,  as 
pointed  out  in  Chapter  XI,  and  the  disease  may  spread  thence  to  the 
penis.  As  the  result  of  lymphatic  obstruction  and  repeated  attacks 
of  dermatitis,  the  skin  and  subcutaneous  tissues  become  enormously 
hypertrophied,  deep  creases  and  folds  form,  and  in  them  dirt  and 
macerated  epithelial  cells  collect,  emitting  nauseating  odors,  and  pre- 
disposing to  ulceration  and  renewed  attacks  of  dermatitis,  eczema, 
erysipelas,  etc.  In  tropical  countries  the  scrotum  may  become  so 
immense  that  the  patient  has  to  push  it  around  before  him  on  a  wheel- 
barrow.   In  this  latitude  the  disease  is  very  seldom  seen.    The  best 


TUMOIiS  OF  THE  SCROTUM 


1063 


trcaiiiicnt  is  excision.  'I'lic  operation  may  prove  didicult,  and  l)lee(l- 
inj:;  usually  is  free;  hnt  it'  asepsis  can  he  maintained,  great  relief  is 
alliirdcd. 

Tumors  of  the  Scrotum  are  unusual.  The  occurrence  of  dermoids 
(seciuestration  cysts)  was  mentioned  in  Chapter  IV  (Fig.  78). 
Papillomas  are  more  fre(iuent,  and  often  undergo  malignant  degen- 


FiG.  989. — Ulcerating  papilloma  of  .scrotum  (epitheliomatous).     Age  thirty-six 
years;  duration  three  and  a  half  years.     Episcopal  Hospital. 


eration  (Fig.  989).  In  former  years  epithelioma  of  the  scrotum  was 
frequentl}^  seen  in  chimney  sweepers,  from  the  irritation  of  the  soot 
which  accumulated  on  the  scrotum  in  these  persons  of  none  too  cleanly 
habits.  At  the  present  day  workers  in  tar  and  paraffin  are  subject 
to  the  same  affection.  The  proper  treatment  of  these  tumors  is 
excision;  this  scarcely  ever  requires  castration,  as  the  malignant 
growth  spreads  widely  in  the  skin  before  attacking  the  testicles. 


CHAPTER   XXIX. 

SURGERY  OF  THE  FEMALE  GENITALS. 

General  Remarks  on  Examination  of  the  Female  Pelvic  Organs. 
— Position  of  the  Patient.  —  The  woman  usually  is  examined  in  the 
''lithotomy  position,"  that  is,  lying  on  her  back,  with  knees  and  hips 
flexed,  and  the  soles  of  the  feet  resting  on  the  bed  or  table  where  she 
lies  (Fig.  990).  Sometimes  the  ''Sims  position"  is  preferred:  here  the 
woman  lies  on  her  left  side,  with  her  left  arm  behind  her  back,  thus 
throwing  her  right  shoulder  forward;  her  right  thigh  is  flexed  upon 
her  abdomen  as  fully  as  possible,  so  that  the  right  knee  rests  upon 
the  table,  while  tlie  left  lower  extremity  is  flexed  onlv  to  a  moderate 


Fig.  990. — Lithotomy  position.     (Findley.) 


degree  (Fig.  991).  Sometimes,  but  not  very  often,  it  is  desirable  to 
examine  the  patient  in  the  standing  position,  or  even  in  the  knee- 
chest  position  (Fig.  992).  In  a  virgin,  vaginal  examination  should 
be  made  only  when  the  patient  is  under  the  influence  of  a  general 
anesthetic.     A  rectal  examination  may  suffice. 

An  examination  of  the  female  pelvic  organs  should  include  (1) 
inspection  of  the  external  genitalia,  (2)  examination  icith  the  speculum, 
and  (3)  bimanual  examination  of  the  internal  genital  organs.  The 
bladder  and  rectum  should  be  empty. 


EXAMIXATJOX   OF   THE   FEMALE   I'ELVIC  ORCIAXS       lOGo 

External  Genitalia.— Note  the  conditioii  of  the  lahia:  iiiHanimatory 
cliaiiiics,  as  in  acute  ^^HKK'occic  \ulvitis  and  vaginitis;  the  cxisti'iice 
of  a  labial  abscess;  the  presence  or  absenee  of  mucous  patches;  edema 
from  i)regiiaiicy  or  jjclvic  tumors;  excoriations  and  hypertrophy  in 
cases  of  pruritus.    Observe  the  state  of  the  hymen;  the  position  of  the 


Fig.  991. — Front  view  of  Sims'  position.      (Findley.) 

carunculae  myrtiformes,  if  present;  and  the  condition  of  the  vulvar 
opening,  whether  normally  closed  or  widely  gaping  as  in  multiparous 
patients  with  relaxed  vaginal  outlet.  The  position  and  condition  of 
the  urethral  orifice  should  be  noted,  especially  the  presence  of  a 
gonorrheal  discharge,  or  the  existence  of  a  caruncle. 


Fig.  992. — Knee-chest  position.     (Findley.) 

Speculum  Examination. — If  the  patient  is  in  the  Sims  position,  the 

(hick-hill  vaginal  speculum  of  Sims  (1845)  should  be  used  (Fig.  993,  2). 
This  is  inserted  with  the  blade  in  the  sagittal  plane,  and  as  soon  as 


1066 


SURGERY  OF   THE  FEMALE  GENITALS 


the  vagina  is  entered  the  blade  is  turned  transversely,  and  is  pushed 
forward  until  the  stem  catches  on  the  fourchette;  then  the  speculum  is 
drawn  backward,  displacing  the  posterior  vaginal  wall  and  rectum  into 


Fig.  993. — 1,  Bivalve  vaginal  speciilum.     2,  Sims'  duck-bill  speculum. 
3,  Speculum  forceps. 


Fig.  994. — 1,  uterine  sound.     2,  sharp  uterine  curette.     3,  dull  uterine  curette. 
4,  placental  forceps.     5,  double  tenaculiun  forceps.     6,  cer\ical  dilator. 


EXAMINATION  OF  THE  FEMALE  PELVIC  ORGANS       10G7 

the  liollow  of  tlie  sacrum,  and  causing  tlic  vagina  to  he  hallooned  with 
air.  This  usually  renders  tlie  cervix  visihlc.  In  the  dorsal  and  lithotomy 
positions  it  is  more  convenient  to  use  a  bivalve  speculum  (Fig.  993,  1): 
this  is  inserted  closed,  witii  the  blades  in  the  sagittal  plane;  as  soon 
as  the  vagina  is  entered  the  speculum  is  turned  transversely,  but 
the  blades  are  not  opened  until  the  speculum  has  entered  its  full 


Fig.  995. — Bimanual  vaginal  examination.     (Dudley.) 

length.  When  the  blades  are  finally  separated,  the  surgeon  endeavors 
to  bring  the  cervix  into  view  between  them.  If  the  speculum  is  too 
small  or  too  short  this  may  prove  difficult.  Several  sizes  should  be 
available.  TOen  the  cervix  is  exposed,  examine  its  size,  its  shape, 
and  its  position;  note  the  presence  or  absence  of  lacerations,  erosions, 
ulcerations;  observe  the  condition  of  the  os,  whether  characteristic 


1068  SURGERY  OF  THE  FEMALE  GENirALS 

of  a  nulliparous  or  parous  patient;  and  especially  note  the  presence 
or  absence  of  a  cervical  discharge  and  its  character — mucous,  purulent, 
bloody,  etc.  In  suspicious  cases  smears  should  be  taken  from  vagina, 
from  urethra,  and  from  cervix  for  microscopical  examination. 

Bimanual  Examination. — After  withdrawing  the  speculum,  insert 
two  fingers  of  the  glo\'ed  hand  into  the  \-agina.  The  beginner  will 
do  best  to  use  both  right  and  left  hands,  alternately,  on  the  same 
patient;  w^ith  the  left  hand  he  will  be  able  to  feel  lesions  on  the  left 
side  of  the  pelvis  which  might  easily  escape  detection  if  the  right  hand 
only  was  used.  First  examine  the  condition  of  the  posterior  vaginal 
wall  and  perineum.  Then  locate  the  cervix,  and  note  its  condition 
(soft  and  characteristic  of  pregnancy;  hard,  with  scar  tissue  from 
previous  pregnancies,  lacerations,  etc.),  its  size,  its  position  (whether 
or  not  displaced  by  pelvic  lesions),  and  its  mobilit}',  or  fixation.  With 
the  aid  of  the  other  hand  above  the  pubes  (Fig.  995),  then  endeavor  to 
palpate  the  fundus  of  the  uterus,  and  note  its  position,  whether  or  not 
it  is  displaced,  whether  movable  or  fixed,  and  finally  the  size  and  con- 
sistency of  the  uterus.  Note  the  presence  or  absence  of  a  mass  in  the 
pouch  of  Douglas;  its  consistency,  fixation,  and  tenderness.  Palpate 
in  turn  each  tube  and  ovary  by  passing  the  vaginal  fingers  first  to  one 
side  and  then  to  the  other  side  of  the  cervix,  and  endeavor  to  locate 
and  outline,  between  these  and  the  fingers  of  the  abdominal  hand, 
the  uterine  adnexa.  No  matter  what  the  age,  social  condition,  or 
history  of  your  patient,  always  exclude  pregnancy  before  reaching  a 
final  diagnosis. 

Preparation  for  Operation  and  After-care. — Enough  has  been  said 
on  this  subject  in  Chapter  XXII  in  reference  to  abdominal  operations. 
But  a  few  words  are  necessary  in  regard  to  vaginal  operations.  It 
is  desirable  to  have  all  such  patients  in  bed,  and  to  have  the  parts 
thoroughly  cleansed  by  douching  twice  daily  for  several  days  before 
operation.  No  operation  should  be  done  while  the  parts  are  acutely 
inflamed,  nor  during  a  menstrual  period  unless  immediate  operation  is 
imperative.  The  bowels  should  be  thoroughly  opened  by  a  purge  given 
early  in  the  day  before  that  set  for  operation,  and  a  cleansing  enema 
should  be  given  at  least  six  hours  before  the  time  of  operation  (the 
previous  evening  if  necessary).  If  a  purge  is  not  given  until  the  night 
before  operation,  the  bowels  may  be  so  loose  as  to  move  during  the 
operation  and  soil  the  wound.  The  bladder  should  be  emptied  just 
before  the  operation.  When  the  patient  is  in  position  on  the  table 
the  vagina  is  thoroughly  washed  with  soap  and  hot  water,  wiped  out 
with  alcohol,  and  douched  with  bichloride  solution. 

After  operation  the  patient  should  remain  in  bed  for  at  least  two 
weeks,  often  longer.  The  bowels  should  not  be  locked  up  by  opiates, 
and  if  they  do  not  move  by  the  fourth  day  castor  oil  should  be  given; 
whenever  possible  an  enema  should  be  avoided.  The  urine  should 
not  be  drawn  by  catheter  unless  retention  occurs;  after  the  patient 
has  urinated  the  vulva  should  be  gently  douched  with  some  hot 
antiseptic  solution  and  gently  dried  and  powdered. 


rONG'EMTA L    MA  LFOh'MA  TJOXS 


lOOU 


Congenital  Malformations.  Tlic  \  ulva  may  Ik'  congenitally  imper- 
forate, l)iit  till'  coiulitioii  is  more  often  due  to  adhesion  ol'  the  lahia 
minora  as  the  result  of  vuKitis  in  eliildhood  (V'\j^. !)!)()).  In  most  eases, 
whether  eon.Ji;enital  or  aequired,  the  oeehidin}^  meml)rane  is  very  thin, 
and  is  n^adily  rni)tiired  l)y  pulling  the  lal)ia  apart  or  by  ruj)turin<f 
adhesions  with  a  grooved  director;  oeeasionally  the  use  of  scalpel  or 
scissors  is  necessary.  Reunion  should  he  prevented  hy  dressing  the 
raw  surfaces  with  horic  acid  ointment  and  the  daily  introduction 
of  a  fold  of  lint. 


Fig.  996. — Adhesion  of  labia  from  vulvitis  in  infancy.     Age  three  years. 
Children's  Hospital. 


Imperforate  Hymen. — Imperforate  hymen  seldom  is  recognized  until 
after  the  age  of  puberty,  when  the  non-appearance  of  the  menstrual 
flow%  and  its  ultimate  damming  up  in  the  vagina  (hematocolpos)  and 
in  the  uterus  (hematometra)  cause  a  local  examination  to  be  made. 
If  these  conditions  continue  unrelieved  for  several  years  a  large  pelvic 
tumor  may  develop,  and  some  danger  exists  of  peritonitis  from  rupture 
of  the  uterus  or  tubes  or  from  leakage  of  the  uterine  contents  through 
the  fimbriated  extremity  of  the  tubes.  Treatment  consists  in  incision 
and  drainage,  and  if  necessary  in  some  form  of  plastic  operation  to 
])revent  cicatricial  contraction. 

Absence  of  the  Vagina. — Absence  of  the  vagina  usuallx'  is  a  congenital 
defect,  but  occasionally  the  vagina  becomes  obliterated  by  cicatricial 
contraction.  If  the  presence  of  a  uterus  and  adnexa  can  be  demon- 
strated (exploratory  laparotomy  may  be  necessary),  attempts  may  be 
made  to  construct  a  new  vagina.  \  arious  external  plastic  operations 
have  been  employed,  but  usually  without  permanent  success.  The 
plan  introduced  by  Baldwin  (1907)  though  the  mortality  is  higher, 
has  given  much  better  results:  a  loop  of  the  small  intestine  is  excluded 
from  the  intestinal  tract,  and  still  attached  to  its  mesentery  (which 
must  be  sufficiently  long)  is  sutured  in  place  between  bladder  and 
rectum,  opening  below  at  the  ^allvar  orifice,  and  being  closed  above 


1070 


SURGERY  OF   THE  FEMALE  GENITALS 


around  the  cervix  uteri.  The  continuity  of  the  intestinal  tract  is 
then  restored  by  end-to-end  or  lateral  anastomosis. 

Stenosis  of  the  Cervix. — Stenosis  of  the  cervix,  usually  from  congenital 
hypoplasia  and  accompanied  by  anteflexion  of  the  uterus,  is  a  frequent 
cause  of  dysmenorrhea  in  girls  and  young  women.  The  dysmenor- 
rhea is  of  the  obstructive  type,  that  is,  it  is  greatest  preceding  the  flow 
which  often  is  delayed  and  usually  is  scanty.  The  patient  usually  is 
sterile,  and  proper  treatment  often  is  followed  by  conception.  The  kink 
in  the  uterus  favors  retention  of  secretions,  and  causes  venous  conges- 
tion, with  resulting  endometritis.  Examination  shows  an  undersized 
but  lengthened  (conical)  cervix  with  pin-i)oint  os,  firm  and  unyielding 
to  the  touch,  and  the  fundus  uteri  close  beneath  the  symphysis. 

Treatment. — Forcible  dilatation,  the  patient  being  anesthetized,  is 
seldom  productive  of  permanent  cure,  even  if  the  operation  is  many 
times  repeated.  It  is  better  to  incise  the  cervix  posteriorly  in  the 
mid-line  almost  up  to  the  internal  os  and  recto-uterine  fold  of  perito- 
neum; a  small  wedge  of  tissue  is  cut  out  on  each  side  (Fig.  997),  and 


Fi<j.  997. — Diulloy's  operation  for  anteflexion.    Patient  in  the  Sims  position.    (Findley.) 

the  cut  surface  on  each  side  is  then  folded  on  itself  so  as  to  pull  the 
anterior  lip  of  the  cervix  backward  {Dudley's  operation,  1891).  If  the 
anterior  lip  is  very  long  it  may  be  excised.  Or  Pozzi's  operation  may  be 
done:  this  consists  in  dividing  the  cervix  bilaterally,  hollowing  out  and 
infolding  upon  itself  each  of  the  four  denuded  surfaces. 
■  Malformations  of  the  Uterus. — Malformations  of  the  uterus  are  not 
very  rare.  Ectopic  pregnancy  may  occur  in  one  of  the  rudimentary 
horns  of  a  uterus  bicornis.  In  cases  of  double  uterus  (uterus 
didelphys)  it  is  best, usually,  to  remove  one  uterus  by  hysterectomy, 
to  prevent  complications  during  a  possible  pregnancy. 

Gonorrhea  in  the  Female. — As  noted  at  p.  1071,  the  occurrence  of 
gonococcic  infection  of  the  genito-urinary  tract  in  the  female  often 
is  not  attended  by  very  acute  symptoms.  The  gonococci  are  deposited 
at  the  vulvar  orifice  or  in  the  vagina  by  mediate  or  immediate  con- 
tagion, and  within  a  few  days  may  produce  acute  urethritis,  vulvitis, 


VULVITIS  AND   VAGINITIS  1071 

and  vaginitis.  Fraiuciitly,  howcNcr,  no  uciite  symptoms  <le\'elop, 
hut  tlie  jj;()iioc()cci  l()(lji;c  and  prolilerute  in  the  vulvo-vaKinal  glands 
(Hart  hoi  in  if  iff)  and  in  the  cervical  glands  (endo-cervicitis)  and  are 
exceedingly  difficnlt  to  dislodge.  When  the  disease  reaches  a  chronic 
stage,  it  persists  indefinitely,  causing  no  particular  disahility  at  times, 
hut  at  others  j)roducing  local  and  distant  disturhances  which  render 
life  a  hurden.  iNloreover,  the  patient  is  a  constant  carrier  of  infection, 
and  this  may  he  conveyed  to  innocent  persons,  especially  children, 
by  mediate  contagion.  Recrudescences  of  the  infection  occur  from 
time  to  time,  and  with  each  new  attack  the  germs  travel  higher  in 
the  genital  tract,  spreading  from  the  cervix  to  the  uterus  (endometritis), 
where  the  infection  does  not  linger,  to  the  tubes,  ovaries,  and  peri- 
toneum; here  occur  acute  and  chronic  salpingitis,  jicJvic  peritonitis, 
pi/os(dpin.v,  tnho-ovarian  abscess,  etc.  These  comi)lications  frequently  de- 
velop first  in  the  puerperium,  especially  after  miscarriages  or  abortions. 

Urethritis. — The  urethra  almost  always  is  affected  w^ien  gonorrhea 
attacks  the  female,  but  the  course  of  the  disease  is  much  less  acute 
in  its  symptomatology,  and  residual  foci  of  infection  are  much  less 
frequent  than  in  the  male.  Occasionally  a  focus  of  infection  remains 
in  the  suhurcthral  glands  of  Skene,  but  abscess  formation  is  extremely 
rare.  These  abscesses  (one  in  each  gland)  protrude  just  below  the 
external  urinary  meatus,  and  pressure  on  them  will  make  pus  exude 
from  their  orifices  in  the  floor  of  the  urethra,  about  0.5  cm.  within 
the  meatus.  They  should  not  be  confused  with  urethral  caruncles, 
which  are  inflammatory  hypertrophies  or  angeiomatous  out-growths  of 
the  urethral  mucous  membrane,  protruding  from  the  urinary  meatus, 
not  beneath  it  through  the  anterior  vaginal  wall.  Some  caruncles 
bleed  or  are  excessi^'ely  painful;  such  should  be  excised,  with  a  wide 
area  of  the  mucosa  from  which  they  spring,  as  recurrence  is  frequent. 

Treatment. — The  treatment  of  gonococcic  urethritis  in  the  female 
is  subordinate  to  that  of  the  vulvitis  and  vaginitis  with  which  it  is 
accom])auie(l. 

Vulvitis  and  Vaginitis. — These  are  exceedingly  common  in  infants 
and  little  girls,  usually  resulting  from  mediate  contagion  through  soiled 
towels,  etc.  In  them  the  symptoms  may  be  very  acute,  as  is  also  the 
case  in  the  young  nullii)ara,  but  in  the  case  of  women  who  have  borne 
many  children  the  vaginal  mucous  membrane  is  much  less  easily 
infected  and  gonococcic  vaginitis  is  rarely  seen.  The  patient  complains 
of  burning  pain,  worse  during  urination  and  defecation;  the  labia 
minora  are  red,  edematous,  and  tender;  there  is  a  profuse  purulent 
exudate,  in  which  gonococci  are  readily  found;  the  vaginal  walls  may 
be  fiery  red,  and  in  rare  instances  exfoliation  of  epithelium  and  ulcer- 
ation may  occur.  The  vulvo-vaginal  glands  of  Bartholin  are  exceed- 
ingly prone  to  harbor  the  infection  for  a  long  time,  and  abscess  forma- 
tion is  very  common  (Fig.  998) ;  indeed  it  may  be  the  first  symptom  to 
bring  the  patient  to  a  physician.  The  vulvo-vaginal  abscess  points 
at  the  posterior  part  of  the  vulvar  opening,  between  the  labium  majus 
and  minus,  and  is  to  be  treated  by  early  and  free  incision,  with  excision 


1072 


SURGERY  OF   THE   FEMALE  GENITALS 


of  the  anterior  wall  of  the  abscess  sac,  or  if  possil)le  by  extirpation 
of  the  entire  gland,  as  recurrence  is  very  common  unless  radical 
treatment  is  adopted  at  the  first.  Occasionally  as  the  result  of  very 
attenuated  infection,  or  from  cicatricial  closure  of  the  duct,  a  cyst  of 
Bartholin's  gland  develops  (Fig.  999) ;  this  is  to  be  treated  by  excision. 


Fig.  998. — Abscess  of  the  vulvo-vaginal 
gland  of  Bartholin.  Duration  three 
days.  Acute  gonorrhea  in  a  patient  aged 
twenty-two  years.  Pennsylvania  Hos- 
pital. 


Fig.  999. — Cyst  of  vulvo-vaginal  gland 
of  Bartholin.  Age  thirty-six  years ;  dura- 
tion fourteen  years.  Attached  by  two 
pedicles  to  right  labium  minus.  Episcopal 
Hospital. 


Treatment.— The  treatment  of  acute  gonococcic  vulvitis  and  vag- 
initis is  best  conducted  with  the  patient  in  bed,  until  the  most  acute 
symptoms  subside.  Great  care  must  be  taken  to  prevent  infection 
of  the  eyes,  as  well  as  conveyance  of  contagion  to  other  patients  by 
instruments,  dressings,  etc.  There  is  very  little  use  in  local  treatment, 
since  injections,  irrigations,  etc.,  are  very  apt  to  spread  the  infection 
further  up  the  genital  tract.  The  patient  should  be  confined  to  liquid 
diet  at  first,  especially  drinking  plenty  of  water;  urinary  antiseptics 
should  be  administered;  and  the  accumulation  and  crusting  of  the 
purulent  discharge  should  be  prevented  by  douching  the  vulva  fre- 
quently with  hot  permanganate  of  potash  solution,  or  some  other 
antiseptic.  The  heat  of  the  solution  is  beneficial  in  itself.  It  may  be 
well  to  leave  a  rubber  tube  in  the  vagina,  to  promote  drainage.  As 
the  discharge  lessens  and  tenderness  becomes  less,  the  rubber  tube 
may  be  substituted  by  a  gl\x-erin  tampon,  changed  daily.  When  the 
chronic  stage  is  reached  the  infection  probably  will  be  found  to  be 
localized  in  the  cervix  or  the  Fallopian  tubes;  the  local  treatment 
of  these  affections  is  discussed  below. 

Chronic  Gonococcic  Vaginitis,  especially'  in  children,  is  most  success- 
fully combated  by  the  use  of  vaccines;  without  their  use  a  leucor- 
rheal  discharge  may  persist  indefinitely,  and  though  no  gonococci 
may  be  found  by  microscopical  examination  on  many  occasions,  any 
local  irritation  may  bring  them  from  their  hiding  places.  In  both 
children  and  adults  a  so-called  "cure"  of  the  disease  usually  means 
only  latency  of  symptoms.  Some  authorities  teach  that  a  woman 
once  infected  with  gonococci  is  always  infected. 


ESDOMKTIilTlS  1()7;^ 

Til  till-  use  of  \a('ciiK's  for  cliroiiif  pmococcif  \af;initis  in  cliildrcii,  I 
liavo  followed  the  direetioiis of  B.  W.  Ihimiltoii  (IDIO):  give  r)(),()()(),()()() 
killed  gonoeocc'i  by  li\  pcHlerinic  injection  every  fifth  day,  increasing 
the  dose  by  10,( )()(),()()()  until  five  injections  have  been  given,  the  last 
dose  l)eing  9(),()()(),(HH)  gonococci.  After  a  ten-day  interxal  repeat  the 
same  treatment  if  ne<'essary.  In  recent  cases  Hamilton  found  that 
six  injections  usually  cured. 

Endocervicitis. — This  usually  is  gonorrheal  in  origin,  mixed  infec- 
tion occurring  subsccjucntly  and  aggravating  the  condition.  The 
chief  symptom  is  a  leucorrheal  discharge,  thick  and  i)urulent.  ]\Ien- 
struation  occurs  irregularly,  and  usually  the  flow  is  greater  than  normal. 
Examination  through  the  speculum  usually  reveals  a  plug  of  tenacious 
muco-pus  protruding  from  the  os.  Microscopically,  the  glands  which 
line  the  cervical  canal  are  seen  to  be  swollen  and  cystic,  and  much 
increase  in  the  stroma  may  occur,  leading  to  hypertrophy  or  elonga- 
tion of  the  cervix.  The  cer\ix  may  ha\e  erosions  or  actual  ulcerations 
on  its  \aginal  surface. 

Treatment. — Treatment  by  })alliative  means  (douches,  tampons, 
local  aj)j)lications  or  argyrol,  iodin,  etc.)  rarely  is  efficient.  Even 
thorough  scraping  of  the  cer\ical  canal,  the  patient  being  anesthe- 
tized, generally  fails  to  efYect  a  cure.  The  best  treatment  is  formal 
excision  of  the  diseased  tissue,  with  plastic  restoration  of  the  cervical 
canal:  the  cervix  is  split  bilaterally,  and  a  wedge  of  tissue  (including 
the  cervical  mucosa)  is  removed  from  each  lip;  then  the  cervical  flaps 
are  folded  upon  themselves  and  their  free  borders  sutured  to  the  mucosa 
at  the  mternal  os  {Schroeders  operation,  Figs.  1000  and  1001). 


Fig.    1000. — Schroeder's  operation:    the  Fig.  1001. — Schrocder's  operation:  the 

shaded  areas  are  excised.  flaps  are  sutured. 

Endometritis. — Endometritis  is  a  much  rarer  affection  than  com- 
monly believed.  ]\Iost  patients  said  to  have  endometritis  have  an 
entirely  different  lesion  as  the  main  cause  of  their  symptoms.  The 
symptoms  of  which  they  complain  are  painful,  prolonged  and  irregular 
menstruation,  leucorrheal  discharge  between  their  periods,  a  certain 
amount  of  backache,  etc.  Examination  shows  the  existence  of  endo- 
cervicitis, or  salpingitis,  or  both;  and  it  is  some  such  lesion,  and  not 
a  possibly  accompanying  but  relatively  insignificant  endometritis, 
which  is  responsible  for  the  symptoms.  Endometritis  which  exists 
as  the  most  important  lesion  usually  results  from  infection  following 
68 


1074 


SURGERY  OF   THE  FEMALE  GENITALS 


abortion,  miscarriage,  or  labor.  Occasionally  the  disease  occurs  in 
the  nullipara  or  in  the  aged;  in  these  instances  it  usually  is  caused  by 
stenosis  of  the  os,  or  displacements  of  the  uterus  which  cause  conges- 
tion or  interfere  with  proper  drainage.  If  the  disease  continues  long 
untreated,  the  entire  uterine  body  may  become  affected  {metritis). 
The  diagnosis  of  endometritis,  except  in  the  rare  virginal  and  senile 
forms,  depends  upon  the  recognition  of  the  symptoms  mentioned  above 
occurring  after  a  miscarriage  or  a  prolonged  convalescence  from 
labor. 


Fig.  1002. — Curettage  of  the  uterus.     (Findley.) 


Treatment. — Much  can  be  done  to  prevent  the  de^'elopment  of 
endometritis  by  avoiding  infection  in  the  puerperium,  but  when  the 
disease  is  fully  established,  treatment  is  not  very  satisfactory.  The 
first  essential  is  to  secure  free  drainage,  by  dilatation  of  the  os,  main- 
tained by  introduction  of  a  glass  drainage  tube  (Wylie's  drain);  the 
hypertrophied  and  diseased  endometrium  should  be  remo^^ed  afthe 
same  time  by  curette  (Fig.  1002),  but  this  step  is  quite  useless  unless 
free  drainage  is  provided  after  the  operation.  The  tube  should  be 
retained  for  several  weeks,  and  may  be  replaced  later  if  necessary.  If 
other  lesions  (endocervicitis,  salpingitis)  exist  they  should  receive 
appropriate  treatment. 

Acute  Metritis. — Acute  metritis  is  seldom  seen  except  in  cases  of 
puerperal  sepsis  (p.  1092). 


SALPINGITIS  1075 

Chronic  Metritis.^Chronic  metritis,  as  noted  above,  usually  is  a 
se(iiifl  of  iu'<,^lc(tc(i  cases  of  endometritis.  At  first  the  uterus  is  large, 
soft  an<l  l)opgy,  but  later  becomes  sclerosed,  though  usually  retaining 
some  enlargement.  Hyaline  degeneration  is  not  infrequent,  and  malig- 
nant changes  may  occur.  The  .symptoms  resemble  those  of  chronic 
endometritis,  but  usually  are  more  .severe  and  often  are  accompanied 
by  pseudo-hysterical  phenomena.  Menorrhagia  is  excessive,  and  the 
patients  become  chronic  invalids.  The  diagnosis  from  small  intersti- 
tial or  submucous  fibroids  may  be  difficult.  The  only  efficient  trrat- 
iiicnf  is  hysterectomy.  The  condition  is  no  more  curable  by  medicine 
or  ])alliativc  local  treatment  than  sclerosis  of  any  other  organ. 

Salpingitis. — Infiammation  of  the  Fallopian  tubes  usually  is  due 
to  the  local  action  of  gonococci,  the  infection  travelling  upward  by 
gradual  steps  from  its  resting  places  in  the  vulva  and  cervix.  Tuber- 
culosis of  the  Fallopian  tubes  has  been  mentioned  in  Chapter  XXII. 

Acute  Salpingitis. — Acute  salpingitis  is  most  frequent  in  nulliparae; 
it  may  occur  during  an  acute  attack  of  gonorrhea  (vulvo-vaginitis  and 
urethritis)  or  may  arise  later  as  the  result  of  some  factor  which  lessens 
the  resistance  of  the  pelvic  organs.  There  is  always  a  certain  amount 
of  peri-salpingitis  (pelvic  peritonitis)  accompanying  acute  inflammation 
of  the  tubes,  and  pathologically  the  condition  is  not  unlike  an  attack  of 
appendicitis,  except  that  the  infecting  organism  is  the  gonococcus  and 
not  the  more  deadly  streptococcus  or  colon  bacillus.  The  symptoms 
are  those  of  peritonitis  localized  to  the  pelvic  region,  usually  more 
marked  on  one  side  than  on  the  other,  and  not  attended  by  notable 
gastro-intestinal  symptoms.  The  tenderness  is  close  to  Poupart's 
ligament,  too  low  and  too  near  the  median  line  for  typical  appendicitis; 
and  the  history  of  the  case  and  vaginal  examination  almost  always 
indicate  the  true  condition. 

Treatment. — Keep  the  patient  in  bed,  and  treat  her  as  for  diffuse 
peritonitis  (p.  811);  there  is  no  fear  of  gangrene  or  perforation  of  the 
tube,  as  there  is  when  the  appendix  is  acutely  inflamed;  and  the  acute 
attack  subsides  almost  invariably  within  a  few  days.  The  exceptions 
are  a  few  cases  of  salpingitis  of  puerperal  origin;  but  most  of  these, 
even,  subside  under  proper  conservative  treatment.  The  mortality 
following  early  operation  is  high;  but  if  recurrent  attacks  of  pelvic 
peritonitis  occur  in  spite  of  conservative  treatment  it  may  become 
necessary  to  operate  before  the  chronic  stage  has  been  reached.  The 
operation  consists  in  removal  of  the  afTected  tube  (salpingectomy, 
p.  1080)  and  of  the  ovary  also  if  this  is  involved.  But  whenever 
possible  no  operation  should  be  done  for  several  months  after  the 
subsidence  of  an  acute  attack;  after  such  an  interval  the  virulence  of 
the  microbes  is  very  much  attenuated,  and  often  the  pus  in  the  tube 
is  found  to  be  sterile. 

Chronic  Salpingitis. — Chronic  salpingitis  is  a  term  used  to  describe 
a  condition  which  is  not  so  much  a  chronic  inflammation  of  the  tubes, 
as  it  is  the  result  of  a  previous  acute  inflammation.  The  tubes  and 
ovaries   are   bound  down  in  adhesions,  often   involving   omentum, 


1076  SURGERY  OF   THE  FEMALE  GENITALS 

sigmoid,  cecum  and  appendix,  and  less  often  the  pelvic  coils  of  small 
intestine.  There  is  difficulty,  and  often  pain,  in  securing  evacuation 
of  the  bowels;  an  aching  sensation,  or  dragging  pain,  is  nearly  constant 
in  the  lateral  pelvic  regions,  especially  when  the  patient  is  on  her  feet; 
referred  pains  (small  of  back,  thighs,  groins)  are  frequently  present; 
there  usually  is  leucorrhea,  with  painful,  profuse,  and  irregular  men- 
struation, and  the  woman  becomes  a  chronic  invalid.  Examination 
shows  the  uterus  and  adnexa  more  or  less  fixed  by  adhesions;  con- 
siderable tenderness  is  present;  and  the  pelvic  organs  cannot  be 
clearly  outlined. 

Treatment  consists  in  removal  of  the  focus  or  rather  foci  of  infection 
{salpingo-odphorcctojiu/),  releasing  the  adhesions,  and  covering  denuded 
peritoneal  surfaces  by  infolding  or  by  omental  grafts.  The  appendix 
usuallv  should  be  removed  also. 


Fig.  1003. — Right  pyosalpinx,  seen  from  posterior  aspect.     The  tube  is  distended, 
pouched,  and  surrounds  the  ovary.     Episcopal  Hospital. 

Pyosalpinx,  or  Pus-tube,  results  from  accumulation  of  the  products 
of  inflammation  within  the  lumen  of  the  Fallopian  tube,  owing  to 
inflammatory  occlusion  of  the  fimbriated  and  uterine  extremities 
(Fig.  1003).  The  exciting  cause  almost  always  is  the  gonococcus,  and 
the  condition  usually  is  a  remote  sequel  of  acute  salpingitis.  It  has 
been  noted  already  that  gonococcic  infection  of  the  tubes  becomes 
attenuated  soon,  and  that  after  several  months  the  contents  usually 
are  sterile.  A  patient  with  pus-tubes  (both  sides  usually  are  diseased) 
as  a  rule  gives  a  history  of  having  passed  through  several  attacks  of 
pelvic  peritonitis;  and  in  many  cases  a  distinct  history  of  the  primary 
infection  can  be  secured.  A  pus-tube  often  follows  the  first  childbirth 
in  cases  where  the  patient  has  been  inoculated  with  not  very  virulent 
gonococci;  thereafter  the  woman  usually  is  sterile.  If  the  pus-tube 
in  such  a  woman  first  begins  to  cause  symptoms  a  number  of  years 
after  the  last  childbirth,  it  may  be  mistaken  for  a  case  of  ectopic 
gestation  (p.  1090).  Frequently'  pus-tubes  exist  for  years  without 
causing  notable  symptoms;  but  in  most  cases  there  is  an  annoying 
leucorrhea,  and  the  patient  may  be  completely  disabled  by  painful 


pyOSALPI\'X   AM)   Tllil)  OVAh'IAX    AliSCESS  1077 

iiilli«'si()iis  to  the  intestinal  tract,  l)y  recurrent  attacks  of  jx-Kic  peri- 
tonitis from  leakat,^'  of  the  contents  of  the  sac,  etc.  On  examination 
it  is  usual  to  Hnd  the  cervix  disphiced,  and  a  mass  in  the  recto-uterine 
pouch,  sometimes  ek'arly  demonstral)k'  as  sjjriuf^ing  from  one  side  or 
other  of  the  uterus;  a  simihir  hut  smaller  mass,  not  large  enouf^h  to 
occup\  the  i)ouch  of  Douglas,  ma\'  he  present  on  the  other  side  of  the 
uterus.  l*us-tul)cs  usually  are  fixed  hy  adhesions,  hut  the\'  may  he 
very  movahle.  and  their  existence  should  not  he  ruled  out  on  the 
fjround  of  mohility  alone.  A  low,  immohile  mass,  esjx'ciaily  if  it 
results  from  puerperal  infection,  almost  always  is  a  pelvic  ahscess; 
|)us-tul)cs  form  a  hifjh,  not  a  low  mass. 

Treatment.  —  If  symptoms  are  present  the  diseased  stru<tures 
should  he  removed.  If  the  woman  is  younjj:  and  the  ovary  healthy, 
it  should  be  left,  only  the  tube  being  remox'cd,  but  in  man\'  cases 
the  ovary  is  degenerated  ("cystic  degeneration"  from  chronic  ooi)h(>r- 
itis,  p.  1078)  and  will  ])rove  useless  or  even  harmful  if  i)reserved.  The 
entire  tube  should  be  removed,  excising  its  interstitial  part  from  the 
uterine  cornu;  in  some  cases,  in  addition  to  the  removal  of  both  tubes 
and  ovaries  it  is  necessary  to  remove  the  uterus  also,  either  to  facili- 
tate the  operation,  or  because  this  organ  itself  is  diseased  (chronic 
metritis).  The  operation  of  salpingo-oophorectomy  is  described  at 
p.  1079.  If  the  woman  complains  of  no  particular  symptoms,  it  often 
is  best  to  do  no  operation.  I  have  known  a  woman  with  an  undeniable 
pus-tube  pass  through  a  normal  pregnancy  and  puerperium  and  give 
birth  to  a  healthy  child. 

Rupture  of  a  pus-tube  is  rare  while  its  contents  are  still  highly  infec- 
tious; when  it  occurs,  it  is  followed  by  diffuse  peritonitis,  which  is  best 
treated  not  by  immediate  operation,  but  by  strict  adherence  to  the 
rules  laid  down  in  Chapter  XXII  for  the  non-operative  treatment  of 
diffuse  peritonitis.  Immediate  operation  has  a  very  high  mortality, 
but  if  the  patient  is  treated  expectantly  the  infection  almost  always 
becomes  localized  again,  frequently  in  the  form  of  a  pelvic  abscess. 

Tubo-ovarian  Abscesses. — This  is  an  abscess  which  involves  both 
tube  and  ovary  (Fig.  1004).  Usually  the  primary  condition  is  that  of 
pyosalpiiLX,  and  the  ovary  becomes  invaded  by  direct  extension.  It 
is  rare  for  an  o\arian  abscess  to  exist  alone,  or  for  it  to  spread  to  the 
tube  secondarily.  But  when  a  small  ovarian  cyst  or  corpus  luteum 
bursts  into  an  adherent  pus-tube,  infection  of  the  whole  ovary  ma}' 
result,  the  tube  and  ovary  then  forming  one  mass.  Sometimes  tube 
and  ovary  are  in  communication  only  through  an  intervening  pelvic 
abscess.  It  is  difficult  to  distinguish  a  tubo-ovarian  abscess  from  an 
ordinary  pus-tube  before  operation,  as  the  symptoms  and  physical 
signs  are  almost  identical. 

Treatment  is  the  same  as  for  pyosalpinx. 

Hydrosalpinx. — Hydrosalpinx,  or  a  collection  of  serous  fluid  in  the 
tube,  sometimes  develops  as  a  terminal  stage  of  pyosalpinx;  often, 
however,  the  collection  of  fluid  appears  to  have  been  serous  from  the 
beginning.     Hydrosalpinx  frequently  develops  on  one  or  both  sides 


1078 


SURGERY  OF   THE  FEMALE  GENITALS 


in  cases  of  uterine  fibroids.      Treatment  is  tliat  of  the  complicating 
condition. 


Fi(i.  1UU4. — Left  tubo-ovarian  abscess,  seen  from  posterior  aspect.     Ruptured  Ijefore 
operation,  causing  fatal  peritonitis  (colon  bacillus).     Epi.scopal  Ho.spital. 

Oophoritis  or  Ovaritis  is  much  less  frequent  antl  produces  much 
less  conspicuous  symptoms  than  salpingitis.  Like  the  latter  condition, 
of  which  it  is  almost  always  a  direct  sequel,  it  may  be  acute  or  chronic. 
The  symptoms  cannot  well  be  differentiated  from  those  of  the  compli- 
cating salpingitis.  In  acute  ovaritis  the  ovary  is  swollen,  tender,  and 
often  prolapsed  into  Douglas's  pouch;  abscess  of  the  ovary  is  rare  unless 
it  is  the  result  of  secondary  infection  of  a  preexistent  ovarian  cyst,  or 
occurs  in  the  form  of  a  tubo-ovarian  abscess,  already  described. 


^_^_^J.s<-~-»^-. ' 

^n 

B^ 

Jtu. 

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^•'^IHlr 

^^S^^w^S^'^ 

Kf^'^K 

y 

R^MH^v 

s^^HHIflll 

^jgttj^yk.j^ 

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W^" 

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^ 

Fig.  1005. — Microcystic  degeneration  of  the  ovary;  the  ovary  to  the  right  shows 
numerous  small  cysts  scattered  over  the  surface;  these  are  Graafian  follicles  which 
have  undergone  cystic  degeneration,  and  which  it  is  said  may  take  on  excessive  growth 
and  develop  into  large  tumors,  or  may  remain  as  here  represented ;  on  the  other  side 
is  shown  a  similar  condition  of  the  ovary  in  section.      (Dudley.) 

Treatment. — In  acute  ovaritis  the  treatment  should  be  the  same  as  in 
cases  of  acute  salpingitis.  If  suppuration  occurs,  the  proper  treat- 
ment is  oophorectomy.  In  chronic  ovaritis  the  ovary  is  the  seat  of 
"cystic  degeneration,"  and  should  be  removed  along  with  the  tube 
if  this  is  diseased  (Fig.  1005);  since  both  ovaries  usually  are  affected. 


SALPINanooi'IIOUKCTOMy 


1070 


it  is  well,  if  the  patient  is  a  youni;;  woinaii,  uiul  a  portion  of  the  ovary 
remains  healthy,  to  leave  it  as  a  transphmt  in  the  abdominal  wound; 
there  are  fair  prospeets  that  it  will  possess  sufficient  function  to 
j)re\cnt  ;in  artificiid  nK'no]);nise. 

Salpingo-oophorectomy.  The  abdomen  is  opened  l)y  a  paraniccHan 
incision  about  tiiree  or  four  inches  long,  above  the  pubes.  In  any 
case  in  which  there  is  any  possibiUty  of  pus  being  present,  the  surgeon 
should  wall  off  the  small  intestines  with  gauze  packs  as  soon  as  the 
l)eritoneuni  is  opened,  and  before  the  i)ehis  is  explored.  Place  the  first 
gauze  i)ack  on  the  right  or  left  side  of  the  pelvic  cavity,  not  in  the 


Fig.  1006. — Isolating  the  pelvic  cavity  bv  the  use  of  gauze  packs. 

(Dudley.) 


(See  Fig.  812.) 


mid-line;  if  the  first  pack  is  inserted  in  the  mid-line  the  intestines  will 
prolapse  into  the  pelvis  on  both  sides  of  it,  and  it  will  be  more  difficult 
to  control  them.  The  second  gauze  pack  is  placed  in  the  mid-line, 
and  the  third  on  the  left,  thus  pushing  the  troublesome  small  intestines 
completely  out  of  harm's  way  (Fig.  lOOG).  If  it  is  known  to  be  a  clean 
case  it  will  facilitate  these  manoeuvres  to  place  the  patient  in  the  Tren- 
delenburg (high  pelvic)  position  as  soon  as  the  abdomen  has  been 
opened;  but  if  there  is  any  danger  of  infection,  it  is  safer  to  isolate 
the  general  peritoneal  cavity  by  gauze  while  the  patient's  body  is 
still  horizontal,  and  then  to  raise  it  into  the  Trendelenburg  position. 


1080 


SURGERY  OF   THE  FEMALE  GENITALS 


If  many  adhesions  are  present  it  may  be  difficult  at  first  to  recog- 
nize anatomical  landmarks.  First  locate  the  fundus  of  the  uterus. 
Sometimes  it  is  covered  by  omentum  or  sigmoid.  Then  cautiously 
and  gently  work  your  fingers  down  behind  it  until  Douglas's  cul-de-sac 
is  reached.  Then  endeavor  to  isolate  the  tubes  and  ovaries  by  blunt 
dissection  with  the  fingers,  working  from  the  mid-line  outward  and 
pushing  the  omentum  and  intestine  away  from  the  pelvic  organs 
rather  than  enucleating  the  latter  from  the  intestines.  It  is  not  very 
difficult  to  tear  a  hole  in  the  intestines  if  undue  haste  or  force  is  em- 
ployed. From  time  to  time  mop  up  the  clotted  blood  which  collects 
in  the  pelvis  as  the  result  of  rupture  of  adhesions.  When  at  last  the 
posterior  surfaces  of  the  broad  ligaments  are  outlined,  turn  your  atten- 
tion to  their  anterior  surfaces,  beginning  at  the  fundus  of  the  uterus 
again,  where  the  attachments  of  the  tube  and  of  the  roimd  ligament 
form  ^•aluable  landmarks,  and  then  work  out  toward  the  sides  of 
the  pehis. 


Fig.  1007. — Salpingo-oophorectomy:  on  the  right  the  suturing  has  been  completed; 
on  the  left  the  method  of  resecting  the  uterine  cornu  is  indicated.     (Dudley.) 

If  few  or  no  adhesions  are  present,  the  tube  and  o^'ary  from  each 
side  can  be  brought  into  the  wound  without  difficulty.  If  the  tube 
only  is  diseased,  it  alone  should  be  removed  (salpingectomy);  or  if 
the  tube  is  healthy  and  the  ovary  diseased,  oophorectomy  should  be 
done.  In  most  cases  both  tube  and  ovary  are  removed  together. 
The  blood  supply  is  readily  controlled  by  a  ligature  around  the  ovarian 
artery,  at  the  lateral  margin  of  the  broad  ligament,  and  another  close 


liUiTII   IXJCRIE^  1081 

to  tli(>  iitcriis,  just  I)(>l()\v  llu;  tiihc,  wIktc  tlic  uterine  and  oxariaii 
arteries  aiiastoniose.  'I'lie  tube  and  <>\ary  are  tiien  cut  free  Iroiu  the 
broad  ligament  and  any  ooziuj^  jjoiiits  toini)()rarily  claniped  in  hemo- 
stats.  The  tube  should  be  removed  by  reseetiuj^  a  wedjie-shajx'd  i)iece 
of  the  uterine  eormi,  unless  the  uterine  tissue  is  ver\'  friable,  and  will 
not  hold  sutures,  when  it  is  sufficient  to  li<;ate  the  uteriix'  stump  of 
the  tube.  The  eut  edges  of  the  broad  ligament  are  then  sutured  by  a 
loek  stitch  of  chromic  catgut,  controlling  any  venous  oozing  (Fig. 
1007).  The  ends  of  the  ligatures  on  the  ovarian,  and  uterine  arteries 
are  then  tied  together,  tlnis  sliorteniiig  tlie  l)road  ligament,  and  retain- 
ing the  fundus  in  proper  position.  I'sually  it  is  well  to  invert  the  edges 
of  the  broad  ligament  by  another  row  of  sero-serous  sutures,  burying 
the  first  row  and  covering  the  uterine  stump  of  the  tube.  This  lessens 
the  chance  of  post-()])erative  adhesions. 

In  some  cases  it  is  safer  to  leave  a  tube  or  gauze  to  drain  the  floor 
of  the  pelvis,  but  where  there  has  not  been  much  soiling  of  the  pelvic 
structures,  and  no  oozing  i)ersists,  the  abdonunal  wound  may  be 
closed  without  drainage. 

Birth  Injuries. — Lacerations  of  the  cervix  and  perineum  are  the 
most  frc(|uent  obstetrical  injuries,  and  often  produce  sucii  distressing 
s\mpt()ms  as  to  demand  operative  relief. 

Lacerations  of  the  Cervix  may  be  unilateral  or  bilateral;  anterior  or 
posterior  lacerations  are  rare,  as  are  stellate  lacerations.  When  these 
patients  reach  the  surgeon  healing  has  occurred,  but  it  is  healing  w^ith 
deformity:  the  cervical  mucosa  becomes  everted,  and  resembles  an 
ulcerated  surface;  erosions  frequently  form  on  the  vaginal  portion  of 
the  cervix,  and  annoying  leucorrhea  frequently  is  present.  If  the 
lacerations  are  very  wide  and  deep,  subsequent  pregnancies  may  ter- 
minate in  miscarriages  from  very  slight  provocation,  or  conception 
may  not  occur  at  all.  Moreover,  carcinoma  of  the  cervix  seldom 
occurs  except  in  the  scar  of  an  old  laceration;  and  this  is  the  chief 
argument  in  favor  of  habitual  operative  treatment.  But  before  any 
operation  is  done  for  laceration  of  the  cervix,  it  is  important  to  remedy 
inflammatory  conditions  in  the  uterus  and  adnexa,  since  the  inter- 
ference with  free  drainage  which  may  result  from  repair  of  a  cervical 
tear  may  cause  retention  of  uterine  secretions,  thus  aggravating  a 
chronic  endometritis  and  perhaps  indirectly  leading  to  the  develop- 
ment of  salpingitis.  At  the  time  of  operation  the  uterine  cavity 
should  be  cleansed  by  the  curette,  and  immediately  after  repair 
of  the  cervix  the  tubal  lesion,  if  any  exists,  should  be  treated  by 
laparotomy. 

Treatment. — The  operation  for  the  repair  of  a  lacerated  cervix  is 
known  as  trachelorrhaphy  {''tracJielopIasty,"  Emmett,  1809).  It  con- 
sists in  denuding  the  torn  surfaces,  excising  the  cicatricial  tissue,  and 
restoring  the  cervix  to  normal  shape  by  sutures.  The  technique  is 
sufficiently  indicated  in  the  accompanying  illustration  (Fig.  1008).  In 
some  cases  where  the  lacerations  are  very  extensive,  or  the  cervix 


1082 


SURGERY  OF   THE  FEMALE  GENITALS 


hypertrophied,   amputation   of    the    cervix    is   required.      Schroeder's 
method  has  already  been  ilhistrated  (p.  lOT))), 

Lacerations  of  the  Perineum  and  Pelvic  Floor  usually  produce  more 
discomfort  than  lacerations  of  the  cervix.  The  levator  ani  muscles 
are  composed  typically  of  three  portions:  a  posterior  portion,  entirely 

beneath  the  rectum,  which  is 
not  of  importance  in  the  pres- 
ent connection;  a  middle  por- 
tion, which  is  closely  applied 
to  the  sides  of  the  rectum; 
and  an  anterior  portion, 
which  meets  with  the  corre- 
sponding fibers  from  the  op- 
posite side,  at  the  perineal 
centre.  In  superficial  tears 
little  more  is  torn  than  the 
juncture  of  these  anterior 
fibers,  and  some  of  the  fibres 
of  the  transversus  perinei,  at 
the  perineal  centre.  In  com- 
plete tears  the  rupture  extends 
down  through  the  perineal 
centre  and  involves  the 
sphincter  ani,  almost  always 
entailing  fecal  incontinence. 
Neither  a  superficial  nor  a 
complete  tear  of  the  perineum 
necessarily  involves  the  pelvic 
floor  proper,  so  there  is  not 
much  loss  of  support  to  the 
pelvic  organs;  it  is  onl}'  when 
the  tear  extends  up  one  or 
both  lateral  sulci  of  the 
vagina,  rupturing  the  middle  fibres  of  the  levator  ani  and  detaching 
them  from  the  sides  of  the  rectum  that  there  develops  a  tendency 
to   hernia  of   the   pelvic  contents  through  the  vulvar  orifice. 

The  symptoms  due  to  this  loss  of  support  in  the  pelvic  floor  are 
chiefly  a  feeling  of  weakness  in  the  pelvis  when  the  patient  stands  or 
walks;  and  dragging  sensations  in  the  lower  abdomen,  with  pains 
referred  oftenest  to  the  ovarian  or  lumbar  regions.  In  typical  cases 
the  vulvar  orifice  gapes,  the  anus  falls  backward  toward  the  coccyx, 
and  descends  to  a  lower  plane,  no  longer  being  placed  in  a  well  marked 
cleft  between  the  nates.  In  many  cases  the  anterior  wall  of  the  rectum 
protrudes  beneath  the  posterior  vaginal  wall,  forming  a  rectocele  (Fig. 
1009);  and  in  connection  with  this  there  often  develops  an  anterior 
colpocele  or  a  cystocele  (p.  1088).  If  the  condition  is  neglected  it  fre- 
quently leads  to  prolapse  or  to  procidentia  of  the  nterus. 


Fig.  1008.— Trachelorrhaphy:  after  excision 
of  the  cicatricial  tissue,  sutures  of  No.  2  chromic 
catgut  are  passed,  beginning  at  the  apex. 
(Findley.) 


I'ERIXEOinniAI'HY 


1083 


Trtatincnt. — TIic  operation  for  the  repair  of  a  lacerated  perineum 
is  known  as  perineorrhaphy."  Its  nature  and  extent  depend  on  the 
character  of  tlie  tear.  If  Uoth  lateral  sulci  of  the  va(jina  are  involved, 
tlic  best  operation  is  of  the  tyi)e  devised  hy  Kmmett  (188.'i):  this 
consists  in  denudinj^:  the  rehaxed  areas,  reunitinji;  tlie  levatores  ani 
muscles  to  the  lateral  rectal  and  posterior  va|;;inal  walls,  and  restoring 
the  external  perineum  hy  transverse  sutures,  known  as  "crown 
sutures."  The  manner  in  which  the  denudation  is  accomplished  is  of 
little  moment;  many  surgeons  follow  Emmett  in  employing  scissors. 
Personally.  I  prefer  the  scalpel,  and  I  am  in  the  hal)it  of  proceeding 


as  Follows: 


Fig.  1009. — Rectocele  and  cystocele.     Pennsylvania  Hospital. 


1.  Denudation. — A  tenaculum  is  placed  at  the  lowest  myrtiform 
caruncle  on  each  side,  and  these  points  are  well  retracted  exposing 
the  rectocele.  A  point  on  this  is  selected,  which  when  draW'U  forward 
by  tenaculum  will  reach  almost  but  not  quite  to  the  urinary  meatus 
(Fig.  1010).  When  these  three  tenacula  are  placed  in  apposition  the 
normal  form  of  the  vulvar  opening  is  restored.  A  fourth  tenaculum 
is  then  placed  in  the  mid-line  at  the  mucocutaneous  juncture.  Point 
h  (Fig.  1010)  is  then  drawn  upward  and  point /downward,  making  the 
line  6/ taut.  The  vaginal  mucosa  is  incised  from  b  to/,  and  the  muco- 
cutaneous border  from  /  to  e  and  from  f  to  d.  The  flap  b  f  e  is  then 
dissected  up  with  scalpel  until  c,  the  apex  of  the  lateral  vaginal  sulcus, 
is  reached;  this  point  becomes  apparent  when  the  points  b  and  e  are 
drawn  widely  apart,  forming  the  lines  b  c  and  e  c  (Fig.  1011).     When 

1  It  was  Parvin's  teaching  that  the  terms  Irnchelorrhaphy  and  perineorrhaphy 
should  be  hmited  to  immediate  repair  of  birth  injuries;  and  that  the  operations 
when  done  at  later  periods  should  be  called  Iracheloplasty  and  perineoplasty.  The 
usual  opei'ation  for  repair  of  a  lacerated  perineum  involves  also  the  vagina,  whence 
the  term  posterior  colporrhaphy  or  colpo-perineorrhaphy. 


1084 


SURGERY  OF   THE  FEMALE  GENITALS 


Fig.  1010. — Typical  incomplete  lacer- 
ation of  the  perineum.  The  tenaculum 
hooked  into  the  crest  of  the  rectoccle  at 
point  b  draws  it  slightly  forward.  The 
other  two  tenacula  are  hooked  into  the 
lowest  remains  of  the  hymen,  points  d 
and  e  (carunculce  myrtiformes) .  The  three 
tenacula  if  apjiroximated  would  brinti  into 
coincidence  points  h,  d,  and  e,  and  would 
show  what  surfaces  should  be  united. 
(Dudley.) 


Fig.  1012. — This  shows  the  surfaces 
denuded  and  ready  for  suturing.  Some 
operators  prefer  to  expose  the  surface 
on  both  sides  for  denudation  in  the 
manner  in  which  they  are  exposed  in  this 
illustration.  In  the  use  of  either  method 
it  is  desirable  to  denude  on  each  side 
somewhat  further  back  into  the  sulcus 
than  is  here  shown.     (Dudley.) 


Fig.  1011.— Same  as  1010.  Tenacu- 
lum at  d  removed  and  placed  at  /. 
Tenacula  b,  e,  and  /  make  traction  so 
as  to  render  tense,  lift  up  and  expose 
for  denudation  the  torn  sulcus  of  the 
left  side.  The  ridges  formed  by  the 
structures  drawn  taut  indicate  the  out- 
line of  the  surface  to  be  denuded. 
(Dudley.) 


the  dissection  has  been  carried  as 
high  as  these  Unes,  the  flap  of 
mucous  membrane  is  cut  free  by 
dividing  it  along  e  c  and  h  c  with 
straight  scissors.  The  same  pro- 
cedure is  then  carried  out  on  the 
patient's  right  side,  until  the  lines 
d  a  and  b  a  are  reached,  when  the 
flap  is  cut  free  by  scissors  passed 
along  these  lines.  The  denuded 
surfaces  now  have  the  appearance 
represented  in  Fig.  1012. 

2.  Suture. — The  method  of  in- 
serting the  sutures  is  important: 
in  a  typical  Emmett  operation  the 
lateral  vaginal  sulci  are  sutured 
first,  beginning  at  the  apex  of  the 
denuded  area  and  working  toward 
the  vaginal  outlet  (Fig.  1013). 
Finally  the  crown  sutures,  usually 
of  silkworm  gut,  are  passed  from 
the  skin  surface  deeply  into  the 
tissues  of  the  perineum  from  one 
side    to    the    other,    uniting    the 


PERINEOliRIIM'IIY 


1085 


k'vatores  aiii  in  the  iiKMlian  line.  Dudley  modifies  this  method  l)y 
makiiifj:  separate  suture  of  the  levatores  ani  with  huried  sutures  and 
then  elosini,'  the  vaginal  sulei  (Fig.  1011).  Finally  the  skin  of  the 
perineum  is  closed. 


Fk7.  1013. — Perineorrhaphy:    method  of  i)assing  sutures  in  one  of  the  hiteral  sulci. 


In  cases  where  the  chief  damage  is  at  the  vulvar  outlet,  it  is  sufficient 
to  suture  the  levatores  ani  alone.  They  are  easily  exposed  through 
an  incision  about  two  or  three 
inches  in  length  along  the  muco- 
cutaneous border,  from  the 
lowest  myrtiform  caruncle  on 
one  side  to  that  on  the  other. 
The  vaginal  mucous  membrane 
is  then  raised  by  blunt  dissec- 
tion, the  le^•ator  ani  on  each 
side  is  identified  and  drawn 
into  the  wound  with  forceps, 
and  is  united  to  its  fellow  of 
the  opposite  side  by  buried 
mattress  sutures  of  chromic 
gut.  The  skin  incision  is  then 
closed. 

In  cases  of  complete   laceration 
of  the  perineum,  it  is  necessary, 
in   addition   to   the   other    oper- 
ative   procedures  indicated,    also 
to    reunite     the     retracted    ends 
of    the    ruptured    sphincter    ani; 
these  should  be  exposed  through 
a     transverse    or     inverted     V- 
shaped   incision  in  front   of    the 
anus,  should   be  accurately  iden- 
tified, and  sutured  to  each  other  by  buried  sutures.     The  retracted 
ends  of  the  ruptured  sphincter  produce  dimples  in  the  skin  of  the 
anus,  and  the  skin  between  the  retracted  ends  is  not  puckered  as  is 
the  rest  of  the  skin  surrounding  the  anus.     When  these  retracted 


Fig.  1014. — All  the  sutures  in  the  two 
lateral  sulci  have  been  introduced  and 
tied.  The  levatores  ani  have  been  united 
in  the  median  line  by  buried  sutures. 
The  crown  suture,  which  brings  together 
the  two  carunculie  niyrtiformes  and  the 
posterior  vaginal  wall,  is  being  tied. 
This  completes  the  intravaginal  part  of 
the  operation.     (Dudlej'.) 


1086  SURGERY  OF   THE  FEMALE  GENITALS 

ends  have  been  sutured  to  each  other  the  skin  is  puckered  normally 
around  the  whole  circumference  of  the  anus. 

Displacements  of  the  Uterus. — Anterior  Displacement. — Anteflexion, 
involving  a  bend  in  the  axis  of  the  uterine  canal,  frequently  accom- 
panies stenosis  of  the  cervix,  and  requires  the  same  treatment  (p.  1070). 
In  anteversion,  which  is  rarer  than  anteflexion,  the  cervix  is  displaced 
backward,  there  being  no  abnormal  bend  in  the  axis  of  the  uterine 
canal.  Usually  the  displacement  is  caused  by,  or  at  least  is  asso- 
ciated with,  pelvic  inflammatory  disease,  and  is  relieved  by  proper 
treatment  of  the  complicating  condition. 

Posterior  Displacement  is  common;  and  here  also  retroflexion  is  more 
usual  than  retroversion.  In  extreme  degrees  the  fundus  occupies  the 
pouch  of  Douglas.  If  the  displacement  follows  pelvic  inflammatory 
disease  the  uterus  may  be  fixed  in  its  malposition  by  adhesions,  and 
may  cause  much  discomfort.  In  cases  due  to  relaxation  of  the  pelvic 
floor,  following  pregnancy,  no  noteworthy  symptoms  may  be  caused 
unless  relaxation  is  so  extreme  as  to  permit  prolapse  of  the  uterus, 
with  its  complicating  lesions. 

Treatment. — In  many  cases  following  pregnancy  {subinvolution  of  the 
uterus),  unattended  by  complicating  lesions,  and  causing  no  severe 
symptoms,  permanent  restoration  of  the  uterus  to  its  normal  position 
may  be  secured  by  mechanical  treatment.  The  fundus  should  be 
replaced  manually  by  the  surgeon  several  times  weekly,  and  its  reten- 
tion in  normal  position  favored  by  inserting  a  tampon  behind  the 
cervix  after  the  fundus  has  been  brought  forward.  Sometimes  a 
pessary  is  employed  for  this  purpose.  The  woman  should  do  no  heavy 
lifting  or  arduous  work  for  months;  should  keep  her  bowels  freely 
opened,  avoiding  constipation  and  its  attendant  straining  in  defeca- 
tion; and  should  wear  no  tight  clothing  which  causes  downward 
pressure  on  the  pelvic  organs.  If  the  uterus  is  subinvoluted,  it  is 
well  for  the  patient  to  spend  much  time  in  bed  at  first.  She  should 
lie  flat  on  the  abdomen  or  in  the  Sims  posture  for  several  hours  each 
day,  and  may  assume  with  advantage  the  knee-chest  posture  for  ten 
or  fifteen  minutes  several  times  daily.  In  most  cases  no  operative 
treatment  is  required,  unless  demanded  by  complicating  lesions. 
Innumerable  operations  have  been  devised  to  hold  the  uterus  forward 
(hysteropexy) .  Shortening  of  the  round  ligaments  in  the  inguinal  canal 
(Alexander,  1882)  presents  the  disadvantage  that  it  does  not  permit 
treatment  of  accompanying  pelvic  lesions;  there  are  exceedingly  few 
cases  in  which  it  is  indicated.  Intraperitoneal  shortening  of  the  round 
ligainents  is  preferable.  The  operation  may  be  done  as  follows:  A 
forceps  is  thrust  through  the  broad  ligament  from  its  posterior 
surface,  just  beneath  the  tube  and  close  to  the  uterus.  This  forceps 
then  grasps  the  round  ligament  about  two  inches  from  its  uterine 
end,  and  draws  it  through  the  broad  ligament  (Fig.  1015).  The 
other  round  ligament  is  treated  similarly,  and  then  the  two  round 
ligaments  are  sutured  to  each  other  and  to  the  posterior  wall  of  the 
uterus  just  back  of  the  fundus  (Webster,  1901 ;  Baldy,  1903).    If  they 


I'h'OLM'SK  OF   rill':   UTERUS 


1087 


arc  sutured  too  low  on  the  uterus  tliey  will  i)ull  the  (rr\ix  forward 
and  increase  the  retro-displacement  of  the  fundus.  J'ciitro-.svspni.mm 
of  the  iifrnis  consists  in  suturin<^  the  fundus  to  the  anterior  ahdominal 
wall,  with  ahsorhahle  sutures;  if  non-ahsorhahle  sutures  are  used,  the 
operation  is  known  as  Ventro-fixation.  The  operation  should  not  be 
done  in  any  patient  who  has  not  reached  the  menopause.  It  is  very 
seldom  indicated  except  as  an  incident  in  the  operative  treatment  of 
fjenital  prolai)se  in  the  female. 


Fig.  1015. — Hysteropexy:  both  round  ligaments  have  been  jjulled  through  the  broad 
ligaments,  and  are  about  to  be  sutured  to  each  other  and  to  the  fundus  of  the  uterus. 
(Baldy.) 


Downward  Displacement.^Usually  this  is  a  sequel  of  retrodisplace- 
ment.  When  the  axis  of  the  uterus  is  changed  so  that  it  corresponds 
with  that  of  the  vagina,  descent  is  almost  invariably  the  sequel.  It 
is  predisposed  to  by  loss  of  support,  the  result  of  lacerations  of  the 
pelvic  floor  and  perineum,  or  of  the  atrophy  which  sets  in  about  the 
time  of  the  menopause;  and  by  increased  pressure  from  above,  such 
as  tumors  of  the  uterus  or  abdominal  organs,  obesity,  tight  lacing, 
straining  in  defecation,  etc.    Several  degrees  of  descent  of  the  uterus 


1088 


SURGERY  OF   THE  FEMALE  CEXITALS 


are  recognized:  in  prolapse  the  uterus  still  remains  in  the  vaginal 
canal,  usually  pushing  before  it  a  cystocele  or  rectocele  (Fig.  lOlGj; 
while  in  procidentia  the  uterus  protrudes  from  the  vulva  (Fig,  1017). 
The  cervix  becomes  hypertrophied  from  passive  congestion  and  fric- 
tion, and  frequently  is  ulcerated.  The  anterior  vaginal  wall  is  pushed 
or  pulled  down  by  the  prolapsing  uterus,  and  anterior  colpocele,  or  even 
cystocele  (prolapse  of  the  bladder  through  the  anterior  vaginal  wall) 
results.  Residual  urine  collects  in  the  bladder  pouch,  and  digital 
pressure  may  be  necessary  to  secure  evacuation  of  urine.  The  occur- 
rence of  posterior  colpocele  and  rectocele  has  been  discussed  at  p.  10S3. 


Fig.  1016. — Prolapse  of  the  uterus; 
large  rectocele;  also  hemorrhoids. 
Pennsylvania  Hospital. 


Fig.  1017. — Procidentia  uteri  and  ulcer- 
ation of  the  cer\-ix.  Patient,  aged  thirty- 
six  j-ears,  has  had  eight  children,  including 
one  set  of  twins.     Pennsylvania  Hospital. 


Treatment  involves  (1)  repair  of  the  anterior  vaginal  wall;  (2) 
repair  of  the  pelvic  floor  and  .perineum;  and  frequently  also  (3)  some 
intra-abdominal  operation  to  secure  the  uterus  in  a  position  of  ante- 
version,  thus  restoring  the  normal  relation  of  the  axis  of  the  uterus 
to  that  of  the  vagina;  (4)  if  the  cervix  is  very  large  it  should  be 
amputated  as  the  first  step  of  the  operation  (p.  1073). 

Repair  of  the  anterior  vaginal  wall  may  be  done  by  making  a  median 
incision  from  just  back  of  the  urinary  meatus  to  a  point  about  an  inch 
in  front  of  the  cervix;  here  the  incision  diverges  in  two  branches,  so 
as  to  form  an  inverted  Y.  This  incision  is  carried  through  the  mucosa 
exposing  the  muscular  wall  of  the  bladder.  The  mucous  flaps  are  then 
reflected  laterally  by  gauze  dissection,  until  the  operator's  finger 
can  detect  the  margins  of  the  rent  in  the  vesico-vaginal  fascia  through 
which  the  hernia  of  the  bladder  has  occurred.  These  fascial  margins 
are  then  sutured  together  in  the  mid-line  by  l:)uried  mattress  sutures 
of  chromic  gut,  taking  care  not  to  penetrate  the  bladder.  If  no  such 
margins  can  be  detected,  the  sutures  should  at  any  rate  be  passed  as 
far  laterally  as  possible,  through  the  outer  layers  of  the  vesical  wall, 


GEMTAL   I'lSTVL^ 


1089 


infolding  this  upon  itself  aiul  thus  overcoming  the  prolapse  of  tlie 
bladder.  The  flaps  of  vaginal  mucosa  are  now  to  be  sutured;  if 
redundant  the  excess  may  be  excised. 

The  operation  for  the  repair  of  a  cystocele  never  is  efficient  unless 
supplemented  hij  repair  of  the  pelvic  floor  and  perineum,  as  already 
described  (p.  1083). 

In  cases  where  the  uterus  is  diseased  and  has  to  be  removed,  great 
care  sliould  be  taken  to  implant  the  stumps  of  the  broad  and  round 
Hgaments  into  the  remains  of  the  cervix  or  the  vaginal  vault,  to  prevent 
prolapse.  In  severe  or  recurrent  cases  the  cervical  stump  may  be 
implanted  in  the  abdominal  wall. 

Genital  Fistulae. — Most  cases  of  genital  fistul*  in  the  female  result 
from  se])aration  of  sloughs  which  have  been  produced  by  i)rolonged 
or  excessive  pressure  during  partu- 
rition. They  are  rare  at  the  jiresent 
day,  owing  chiefly  to  the  advances 
in  obstetrics.  Some  occur  as  the 
result  of  careless  operating  (Fig. 
1018),  and  others  from  ulceration 
due  to  inflammation  or  malignant 
disease.  All  except  the  latter  usu- 
ally may  be  cured  by  operative 
treatment.  By  far  the  commonest 
form  of  fistula  is  the  vesicovaginal; 
other  fistulse  (vesico-uterine,  recto- 
vaginal, recto-uterine,  uretero-cervical, 
etc.)  are  comparatively  very  rare. 
The  diagnosis  depends  on  the  recog- 
nition of  the  leakage  of  urine  or 
fecal  matter  (or  even  merely  flatus) 
into  the  genital  tract.  Injection  of 
the  bladder  or  rectum  with  colored 
fluids  (milk,  methylene  blue,  etc.) 
renders  this  fact  certain.  In  most 
cases  the  fistula  can  be  brought  to  view  by  use  of  a  speculum. 
Uterine  fistulse,  however,  cannot  be  thus  exposed. 

Treatment. — Preparator\-  treatment  before  operation  is  of  the 
utmost  importance.  The  phosphatic  deposit  of  urinary  salts  around 
the  margins  of  the  fistula  must  be  removed  gently,  and  their  reforma- 
tion prevented  by  rendering  the  urine  acid.  The  patient  must  drink 
plenty  of  water;  copious  hot  vaginal  douches  should  be  given  to  cleanse 
the  parts,  and  the  dermatitis  of  the  vulva  and  adjacent  skin  should 
also  be  relieved  by  appropriate  remedies.  After  operation  the  patient 
remains  in  bed  about  three  weeks,  and  for  the  first  two  weeks  constant 
vesical  drainage  is  assured  by  the  use  of  an  inlying  catheter  (prefer- 
ably glass,  with  appropriate  curve),  which  must  be  changed  frequently. 

1.  When  the  fistulous  tract  can  be  exposed  from  below,  it  is  usually 

possible  to  close  it  by  a  plastic  operation.    The    edges  of  the  fistula 

69 


Fig.  1018.  —  Recto-vaginal  (recto- 
vestibular)  fistula  following  attempted 
repair  of  a  laceration  of  the  perineum. 
Pennsylvania  Hospital. 


1090  SURGERY  OF   THE  FEMALE  GENITALS 

are  pared  obliquely,  at  the  expense  of  its  vaginal  surface,  and  in  an 
oval  form  (Fig.  1019).  The  flap-splitting  method  seldom  is  required. 
2.  When  the  fistulous  tract  cannot  he  exposed  frorn  below,  as  is  usually 
the  case  in  fistula?  which  involve  the  uterus,  laparotomy  becomes 
necessary.  The  bladder  is  carefully  separated  from  the  uterus,  and 
the  opening  in  each  repaired  separately.  Hysterectomy  may  render 
the  operation  easier  or  the  cure  more  certain. 


Fig.  1019. — Vesico-vaginal  fistula,  showing  the  proper  area  of  denudation.     Left 
lateroprone  position;  exposure  by  Sims'  speculum.     (Dudley.) 

Extra-uterine  Pregnancy. — Ectopic  gestation  usually  occurs  in  the 
tube,  and  in  most  cases  rupture  of  the  tube  occurs,  or  the  embryo 
is  discharged  into  the  peritoneal  cavity  through  the  fimbriated  ex- 
tremity of  the  tube  {tubal  abortion),  from  the  sixth  week  to  the  third 
month  pregnancy.  Occasionally  rupture  occurs  into  the  cellular 
tissue  of  the  broad  ligament;  this  is  least  unusual  when  pregnancy 
occurs  in  the  tube  close  to  the  uterine  wall  {ampullar  pregnancy), 
or  as  an  interstitial  pregnancy  in  that  portion  of  the  tube  within  the 
uterine  wall.  In  the  latter  case  an  intra-uterine  abortion  may  occur. 
After  rupture  or  tubal  abortion  the  embryo  usually  dies,  but  in  rare 


EXTRA-UTERINE  r  REG  NANCY 


1091 


cases  it  continues  to  grow  (secondary  abdominal  i)regnancy)  almost 

to  full  term. 

The  causes  of  extra-uterine  pregnanc\-  are  obscure.  It  occurs 
oftenest  in  women  who  have  been  sterile  for  five  years  or  more,  and 
is  thought  to  be  predisposed  to  by  previous  attacks  of  salpmgitis, 
or  congenital  peculiarities  of  the  tube  (long  and  tortuous,  with  small 
lumen  or   with  diverticula). 


Pm  iO'?U —Ruptured  tubal  pregnancy;  an  eight  weeks'  fetus.  Age  twenty-three 
vears  'one  childbirth,  four  vears  ago;  had  missed  one  period,  and  had  had  prenionitory 
svmptoms  for  three  days.  Admitted  to  hospital  with  diagnosis  of  peritonitis;  pulse. 
150-  temperature,  98°  F.;  leukocytes,  45,000;  polynuclears,  94  per  cent.;  hemoglobin. 
35  per  cent.  Correct  diagnosis  based  on  anemia.  Operation  fifteen  hours  after  rupture. 
Rccoverj-.    Episcopal  Hospital. 

Symptoms  and  Diagnosis.— The  usual  early  symptoms  of  normal 
pregnancy  may  or  may  not  be  present;  these  include  particularly, 
morning  sickness,  increase  in  size  of  breasts,  perhaps  with  pigmenta- 
tion. In  almost  all  cases  there  is  a  disturbance  of  the  normal  menstrual 
periodicitv:  often  one  period  is  missed  and  this  is  followed  in  a  week 
or  so  by  irregular  and  scanty  bleeding.  Painful  cramps  may  or  may 
not  occur  in  the  uterus.  If  vaginal  examination  is  made,  the  presence 
of  a  mass  in  the  tube  usually  can  be  determined.  It  may  be  difficult 
to  distinguish  this  from  a  pyosalpinx,  but  in  the  latter  there  should 
be  no  concomitant  symptoms  or  signs  of  pregnancy.  In  ectopic 
gestation  the  uterus  usually  is  somewhat  enlarged  and  the  cervix  is 
softened.  In  the  vast  majority  of  cases  the  patient  does  not  come 
under  the  care  of  a  physician  until  rupture  of  the  tube  occurs.  This 
is  attended  by  agonizing  pain,  frequently  so  severe  as  to  cause  faint- 
ness,  and  is  followed  by  more  or  less  profuse  internal  hemorrhage 
evidenced  by  the  usuaf  signs.     Indeed,  symptoms  of  severe  internal 


1092  SURGERY  OF   THE  FEMALE  GENITALS 

hemorrhage  in  a  woman  previously  in  good  health  almost  always 
are  clue  to  the  rupture  of  an  ectopic  gestation  sac.  In  a  minority  of 
cases  the  bleeding  occurs  so  slowly  that  no  very  acute  symptoms  are 
produced,  and  the  blood  collects  in  the  pelvis  in  the  form  of  a  pelvic 
hematocele.^ 

Treatment. — If  the  condition  is  recognized  before  rupture  or  tubal 
abortion  occurs,  the  affected  tube  should  be  removed  at  once.  Exactly 
the  same  treatment  is  required  when  rupture  has  occurred.  Some 
authorities,  notably  Simpson  of  Pittsburgh,  contend  that  the  hemor- 
rhage always  will  cease  of  itself,  and  that  no  operation  should  be  done 
until  the  symptoms  indicate  that  this  has  taken  place.  The  majority 
of  surgeons  and  gynecologists,  howe\'er,  still  believe  that  less  risk  is 
run  by  immediate  operation,  even  in  the  presence  of  profound  shock 
from  hemorrhage,  than  by  delay.  Very  little  anesthetic  is  required. 
The  abdomen  is  rapidly  opened  above  the  pubes,  the  hand  is  intro- 
duced and  feels  for  the  uterine  appendages;  usually  there  are  no 
adhesions,  and  it  is  very  easy  to  tell  by  the  sense  of  touch  which  is 
the  affected  tube,  even  if  this  has  not  been  ascertained  before  opening 
the  abdomen.  The  ruptured  tube  is  brought  into  the  wound  and  the 
bleeding  temporarily  checked  by  the  fingers.  The  diseased  tube, 
usually  with  its  corresponding  ovary,  is  then  removed;  the  clotted 
and  semi-fluid  blood  is  removed  by  forceps  and  gentle  sponging, 
but  no  irrigation  is  employed.  It  is  well  to  pass  the  hand  into  each 
kidney  pouch  and  evacuate  the  clots  which  have  accumulated  there. 
If  the  operation  is  done  soon  after  rupture,  and  if  most  of  the  effused 
blood  and  clot  can  be  removed,  the  wound  may  be  closed  without 
drainage.  In  late  cases,  especially  if  there  is  any  suspicion  of  secondary 
infection  of  the  clot  from  the  adjacent  intestinal  tract  (not  very  rare) 
it  is  safer  to  drain  the  pelvis  for  a  few  days.  Bilateral  tubal  pregnancy 
may  occur,  and  it  is  always  desirable  to  examine  both  tubes  before 
closing  the  abdomen. 

Puerperal  Sepsis. — Many  cases  of  septic  infection  develop  from 
the  genital  tract  during  parturition  and  the  puerperium.  This  is 
owing  chiefly  to  the  ignorance  and  carelessness  of  midwives  or  incom- 
petent general  practitioners;  but  sometimes  it  is  unavoidable,  being 
due  solely  to  a  preexistent  infection,  or  to  self-induced  abortion. 
The  prevention  of  such  infection  is  in  the  realm  of  obstetrics;  but  its 
treatment  frequently  falls  to  the  lot  of  the  general  surgeon,  and  it 
behooves  him  to  be  prepared  to  do  the  best  that  is  known  for  these 
unfortunate  patients. 

The  infection  usually  takes  its  origin  at  the  placental  site  or  in  the 
lacerated  cervix;  occasionally  from  lacerations  in  the  vagina  or  at 
the  vulvar  orifice.  If  fetal  products  are  retained,  and  become  infected 
by   putrefacti^'e  microorganisms,  sapremia  develops   (p.  75).      This 

1  Rupture  of  a  rctcniion  cyst  of  the  ovary  occasional!}'  is  followed  b}^  severe  internal 
hemon'hage  which  may  be  indistinguishable  from  that  due  to  ruptured  tubal  gesta- 
tion (p.  1097).  I  have  encountered  two  such  cases.  The  treatment  is  the  same 
as  for  ruptured  extra-uterine  pregnancy. 


PVEIiVERAL  SEPSIS  HlOH 

is  coninioiier  than  invasion  hy  jjathofjenio  bacteria,  resulting  in  sep- 
ilroniit:  the  latter  may  arise  as  a  seeoiuhiry  cdndition  in  a  case  of 
sapreniia,  hut  more  often  is  a  ])riniary  condition.  Finally,  if  septic 
thronibosi  occurs,  witli  the  hMJgenient  of  secondary  emboli,  the  con- 
dition is  described  as  puerperal  pyemia. 

Retained  Secundines. —  It  may  hapjx'n  after  labor  (i)articularly 
in  cases  of  mis(arria<j;e  or  abortion)  that  some  of  tlie  fetal  tissues  are 
retained.  The  question  arises  whether  their  expulsion  shall  be  left 
to  nature,  or  whether  they  shall  be  removed  by  a  surgeon.  While 
there  is  no  doubt  that  in  a  great  many  such  cases  the  unaided  power 
of  nature  is  sufficient,  yet  I  think  surgical  intervention  hastens  con- 
valescence, and  is  to  be  recommended  provided  it  is  certain  that 
secundines  have  been  retained  for  several  days.  If  this  fact  is  uncer- 
tain, as  it  is  in  a  great  many  cases,  it  is  better  to  wait  several  days 
longer  and  to  evacuate  the  uterus  surgically  only  when  evidences  of 
sapremia  become  manifest. 

Sapremia. — Local  changes  are  confined  mostly  to  the  endometrium 
{putrid  endometritis)  which  is  covered  with  brownish-gray  pulpy 
sloughs,  with  exceedmgly  foul  odor.  Sapremia  occurs  oftenest  after 
full  term  labors  or  miscarriages  near  term.  Symptoms  usually  do 
not  appear  until  the  fourth  day  or  later,  and  consist  essentially  in 
elevation  of  temperature  (perhaps  as  high  as  105°)  and  other  phe- 
nomena of  fever,  with  foul  smelling  discharge  from  the  cervix. 

Treatment. — As  soon  as  such  symptoms  manifest  themselves,  the 
uterus  should  be  completely  evacuated.^  This  is  best  done  by  the 
gloved  finger,  covered  with  gauze,  or  with  the  placental  forceps,  if 
the  cervix  will  not  admit  the  finger  easily.  If  a  curette  is  used,  it 
should  be  the  dull  curette,  but  even  a  dull  curette  is  dangerous  under 
such  circumstances.  It  is  very  easy  to  perforate  the  puerperal  uterus, 
especially  if  diseased.  The  surgeon  should  adopt  some  system  in 
cleaning  out  the  uterus,  and  should  make  sure  that  no  large  mass  of 
decomposing  tissue  is  left  behind.  On  several  occasions  I  have  been 
forcetl  to  repeat  the  operation  for  persistence  of  symptoms,  removing 
large  masses  of  foul  smelling  necrotic  placenta  which  had  been  over- 
looked by  the  previous  operator.  If  bleeding  is  free,  the  uterine  cavity 
shoukl  be  packed  with  iodoform  gauze,  which  is  left  in  place  for  two 
days;  and  a  full  dose  of  ergot  should  be  administered.  If  no  note- 
worthy bleeding  occurs,  a  gauze  wick  may  be  left  within  the  cervix, 
or  if  this  tends  to  contract  too  much  to  permit  free  drainage,  a  rubber 
tube  should  be  passed  through  the  cervix  into  the  uterine  cavity. 

After  prompt  evacuation  of  such  a  uterus  the  temperature  rapidly 
falls,  and  uninterrupted  convalescence  is  the  rule  (Fig.  31,  p.  74). 

//  j)erforation  of  the  uterus  is  suspected,  the  uterine  cavity  should 
be  lightly  packed  with  gauze,  and  subsequent  developments  awaited. 
//  perforation  is  certain,  and  especially  if  the  operator  has  dragged 

1  It  is  needless  to  saj'^  that  all  such  patients  should  be  sent  to  a  well-equipped 
hospital  and  put  in  charge  of  a  competent  surgeon.  But  etherization  is  not  always 
necessary. 


1094 


SURGERY  OF  THE  FEMALE  GENITALS 


down  bowel,  mistaking  it  for  retained  placental  tissues,  the  abdomen 
should  be  opened  at  once  (by  a  competent  surgeon),  and  the  damage 
repaired. 

Septicemia. — This  may  occur  after  full  term  parturition  (especially 
if  instrumental),  but  is  most  frequent  as  the  result  of  criminal  abor- 
tions in  the  early  months  of 
pregnancy.  There  is  septic  en- 
dometritis,  with  adherent  false 
membrane  over  denuded  areas, 
and  purulent  blood-stained  dis- 
charge, almost  always  accom- 
panied by  acute  septic  metritis, 
evidenced  by  an  edematous 
boggy  uterus.  Infection  may 
spread  to  the  peritoneum  {peri- 
metritis, acute  septic  pelvic  peri- 
tonitis, Fig.  1021)  and  to  the 
subperitoneal  cellular  tissues 
{parametritis,  acute  septic  pelvic 
cellulitis).  The  blood  sinuses  in 
the  uterine  walls  become  the 
seat  of  septic  thrombosis,  and  this 
may  extend  to  the  uterine  and 
ovarian  veins,  resulting  event- 
ually in  puerperal  pyemia  (see 
below).  Perivascular  lymplian- 
geitis  may  occur,  and  if  exten- 
sion of  the  thrombus  to  the  external  iliac  and  femoral  veins  takes 
place,  "milk  leg"  results  (p.  240). 

Symptoms. — The  onset  of  puerperal  septicemia  occurs  earlier  than 
that  of  sapremia,  usually  on  the  second  or  third  day  after  dehvery. 
The  disease  often  is  ushered  in  by  a  chill,  and  the  constitutional 
symptoms  are  much  more  severe  than  the  local.  The  temperature 
rises  to  great  heights  and  falls  again  rapidly  and  at  irregular  intervals 
(Fig.  28,  p.  72) ;  the  pulse  is  persistently  rapid  and  weak.  Chills  may 
occur  only  once  or  twice  in  the  course  of  the  disease,  or  several  times 
daily,  but  at  irregular  intervals.  Frequent  chills  usually  indicate 
pyemia.  Unless  peritonitis  sets  in,  and  except  during  the  chills,  the 
patient  suffers  little;  often  she  feels  quite  well,  except  for  weakness, 
even  when  most  gravely  ill.  There  may  be  little  found  in  the  pelvis 
to  account  for  the  symptoms:  usually  the  uterus  is  larger  than  normal, 
and  the  discharge  may  be  purulent,  but  it  does  not  possess  the  foul  odor 
characteristic  of  putrefaction,  unless  sapremia  was  the  primary  condi- 
tion. Early  in  the  disease  the  uterus  is  not  fixed,  and  the  abdomen 
usually  is  soft  and  full.  Only  if  salpingitis  or  pelvic  peritonitis  exists  is 
there  local  rigidity  and  tenderness.  It  is  when  the  infection  is  confined 
to  the  extraperitoneal  structures  (pelvic  cellulitis),  that  the  patient  feels 
so  well  subjectively.     By  the  end  of  the  first  week  of  the  disease, 


Fig.  1021. — Puerperal  sepsis:  Pelvic  peri- 
tonitis with  suppurative  perimetritis,  and 
parametritis.     (After  de  Quervain.) 


PUERPERAL  SEPSL^  109;") 

rari'ly  earlier  and  ottcii  iimch  later,  tlie  uterus  may  hecome  fixed, 
and  a  pelvic  mass  may  he  detected.  In  some  cases  during  the  second 
or  third  week  the  throuihosed  uterine  and  ovarian  veins  may  be 
palpated  in  the  broad  ligament. 

Treatment. — In  every  case  I  believe  it  is  well  to  make  sure  that  the 
uterus  retains  no  necrotic  material.  Indeed  it  must  be  confessed  that 
the  diagnosis  between  sapremia  and  septicemia  often  cannot  be  made 
until  after  the  uterine  cavity  has  been  explored.  If  necrotic  material 
is  found,  and  rapid  improvement  follows  its  removal,  it  usually  is 
safe  to  assume  that  the  condition  was  one  of  sapremia;  if  on  the  other 
hand,  septic  symptoms  continue  it  is  evident  that  the  infection  has 
entered  the  uterine  walls  and  has  become  systemic.  Attempts  have 
been  made  to  eradicate  the  entire  focus  of  disease  in  these  cases  by 
prompt  removal  of  the  uterus;  but  the  mortality  following  the  opera- 
tion is  too  high  to  justify  its  employment  at  this  stage.  Some  weeks 
or  months  later  hysterectomy  may  be  necessary,  to  remove  a  uterus 
riddled  with  abscesses. 

As  early  as  possible  cultures  should  be  made  from  the  interior  of  the 
uterus.  In  most  cases  the  streptococcus  is  the  infecting  organism; 
and  if  the  patient  is  seen  early  enough  (within  two  or  three  days  of 
onset)  it  may  be  worth  while  to  employ  large  doses  of  antistreptococcic 
serum,  or  a  polyvalent  serum.  But  unless  massive  doses  (50  to  150 
c.c.  in  twenty-four  hours)  are  employed  early  in  the  disease,  this 
remedy  appears  to  be  useless. 

Further  than  this,  nothing  remains  but  to  provide  careful  nursing; 
to  ensure  the  taking  of  plenty  of  proper  nourishment  and  abundance 
of  water  (continuous  proctoclysis,  hypodermoclysis,  etc.);  and  to 
watch  the  pelvic  condition.  Vaginal  examinations  should  be  made 
not  oftener  than  once  in  three  days;  great  gentleness  should  be  used, 
and  note  should  be  made  of  the  mobility  of  the  uterus,  the  presence 
of  a  mass,  or  of  thrombosed  ovarian  veins.  A  pelvic  mass  under  these 
circumstances  is  placed  low  in  the  pelvis,  fixed  to  the  uterus,  and  usually 
on  one  side  or  the  other,  though  often  extending  behind  the  cervix. 
Often  the  abscess  tends  to  point  above  Poupart's  ligament  (Fig.  1022). 
Many  authorities  consider  that  all  such  abscesses  have  their  origin 
in  the  pelvic  cellular  tissues,  and  are  entirely  extraperitoneal.  Some 
of  them  I  am  sure  are  ordinary  residual  pelvic  abscesses,  the  sequel 
of  diffuse  peritonitis.  The  distinction  is  of  little  practical  importance, 
but  a  very  important  point  is  to  open  all  such  masses  without  invading 
the  healthy  peritoneal  cavity.  A  pelvic  mass  the  result  of  gonococcic 
infection  (pyosalpinx,  tubo-ovarian  abscess)  is  placed  higher  in  the 
pelvis,  and  its  onset  does  not  date  from  an  instrumental  delivery  or  a 
miscarriage  (Fig.  1028).  Such  an  abscess  may  be  opened  transperi- 
toneally  with  safety,  providing  the  operation  is  not  done  for  three  or 
four  months  after  the  acute  onset  (p.  1075).  But  abscesses  which  result 
from  puerperal  infection  usually  are  streptococcic  in  origin,  and  if  the 
peritoneum  is  opened,  even  many  years  after  the  acute  onset,  fatal 
peritonitis  frequently  develops.    The  abscess  should  be  incised  through 


1096 


SURGERY  OF   THE  FEMALE  GENITALS 


the  posterior  vaginal  vault,  or  above  Poupart's  ligament.  No  opera- 
tion should  be  undertaken  as  a  mere  exploration,  but  only  when  the 
existence  of  suppuration  is  fairl}'  certain. 


Fig.  1022.  —  Puerperal  sepsis:  pelvic 
abscess  extending  low  in  the  pelvis  and 
pointing  above  Poupart's  ligament.  (After 
de  Quervain.) 


Fig.  1023. — Double  pj-osalpinx,  with 
moderate  serous  perisalpingitis.  The 
masses  are  placed  higher  in  the  pelvis 
than  those  which  result  from  puerperal 
sepsis.     (After  de  Quervain.) 


Vaginal  Pmichire. — The  cervix  is  pulled  down  and  forward  by 
volsellum  forceps,  and  a  transverse  incision  is  made  about  two  inches 
long,  just  posterior  to  the  cervix.  When  the  vaginal  wall  has  been 
incised,  the  knife  is  laid  aside,  and  the  abscess  is  opened  by  the  finger, 
or  b}'  Hilton's  method  (p.  51).  The  cavity  is  drained  by  gauze  and 
rubber  tube. 

Extraperitoneal  Incision. — If  the  abscess  points  near  Poupart's 
ligament,  it  is  easily  evacuated  through  a  small  IMcBurney  incision. 
When  the  layers  of  the  abdominal  wall  have  been  incised,  great  care 
is  required  not  to  injure  the  peritoneum,  or  to  break  up  isolating 
adhesions  if  the  abscess  is  intraperitoneal  in  origin.  The  surgeon 
should  burrow  down  cautiously  along  the  pelvic  wall  until  pus  is 
found.     The  abscess  ca\'ity  is  then  drained  by  rubber  tube  and  gauze. 

Pyemia. — Puerperal  pyemia,  as  already  noted,  results  from  the 
detachment  of  septic  emboli  in  the  peri-uterine  veins.  Repeated 
chills,  and  the  appearance  of  metastatic  foci  of  infection  are  the 
two  main  diagnostic  points.  Embolic  pneumonia  is  frequent.  Other 
foci  are  less  usual,  but  recovery  may  ensue  after  multiple  arthritis, 
conjunctivitis,  subcutaneous  abscesses,  and  even  after  cerebral 
embolism. 


OVARIAX   AND   PAROVAIilAN   CY.'^TS  1097 

Trcatincnt. — Whoii  throiiihost'd  ovuriuii  veins  can  he  felt  on  vaginal 
examination,  and  the  cHnical  symptoms  of  pyemia,  especially  recurring 
chills,  are  j)resent,  it  has  heen  ])ro]><)se(l  to  f)pen  the  abdomen  and 
ligate  the  veins  ahove  the  limits  of  thr()nil)Osis,  or  even  to  excise  the 
infected  thromhi,  as  is  done  in  jugular  thrombosis  (p.  240).  The 
operation,  though  it  may  be  difficult,  is  seldom  impossible;  but  some- 
times the  thrombus  is  found  to  extend  so  high  (to  the  renal  veins 
or  \ena  ca\a)  or  may  involve  so  many  trunks  (internal,  common  and 
external  iliac),  that  the  operation  will  have  to  be  abandoned.  But 
as  the  mortality  following  this  operation,  in  collected  statistics,  varies 
from  20  to  55  per  cent.,'  and  the  general  mortality  of  the  condition 
for  which  it  is  recommended  is  from  55  to  80  per  cent.,  in  cases  treated 
without  operation,  it  is  apparent  that  in  carefully  selected  cases  it  is 
a  procedure  worthy  of  careful  consideration. 

TUMORS    OF   THE    FEMALE    GENITAL   TRACT. 

Ovarian  and  Parovarian  Cysts  and  Tumors. — Ovarian  Cysts  may 
be  classified  as  retention  cysts  and  cystadenoinas.  Dermoid  cysts 
(teratomas)  are  discussed  at  p.  1101. 

Retention  Cysts  of  the  Ovary. — Reference  has  already  been  made, 
at  p.  l07cS,  to  cystic  degeneration  of  the  ovaries,  usually  associated  with 
chronic  ovaritis,  and  probably  due  to  thickening  of  the  stroma;  the 
cysts  usually  are  small,  multiple,  and  appear  not  only  on  the  surface 
of  the  ovary,  but  are  scattered  throughout  its  structure  (Fig.  1005). 
Apart  from  the  associated  lesions,  they  produce  no  symptoms  and 
require  no  treatment. 

A  retention  cyst  of  the  Graafian  follicle  usually  is  larger  than  the 
cysts  found  in  cystic  degeneration  of  the  ovary;  it  almost  always  is 
single,  and  is  attached  to  the  ovary  by  a  rather  wide  base.  It  is  lined 
by  cylindrical  epithelium,  but  in  the  larger  cysts  this  becomes  atrophied 
from  pressure.  If  it  is  large  enough  to  produce  symptoms,  the  differ- 
ential diagnosis  from  tubal  and  other  ovarian  enlargements  becomes 
important.  Usually  it  is  found  to  be  the  size  of  a  hen's  egg  or  small 
orange,  and  freely  movable  in  the  pehis,  though  attached  by  a  pedicle 
to  the  uterus.  Its  contents  are  clear,  unless  blood-stained  from  intra- 
cystic  hemorrhage.  Intraperitoneal  rupture,  with  or  without  bleeding, 
may  occur;  and  if  bleeding  is  profuse  the  condition  resembles  that 
seen  in  ruptured  ectopic  pregnancy  and  requires  the  same  treatment. 
Excision  of  the  cyst  and  suture  of  the  defect  in  the  ovary  is  the  proper 
treatment  for  the  unruptured  cyst;  removal  of  the  entire  ovary  is 
undesirable  unless  the  patient  has  reached  the  menopause. 

The  corpus  luteum  cyst  is  another  type  of  retention  cyst  of  the  ovary. 
The  contents  usually  are  dark  and  tarry,  and  the  cyst  wall  is  not 
tense.  Without  histological  examination,  which  shows  typical  lutein 
cells  (pigmented  round  cells)  but  no  epithelium  in  the  lining  membrane, 

^  Michels  in  1909  collected  64  such  operations,  with  31  deaths  (48  per  cent.); 
but  J.  W.  Williams  (1909)  reported  5  cases  in  his  own  experience  with  only  1  death. 


109S  SURGERY  OF  THE  FEMALE  GENITALS 

the  diagnosis  from  the  Graafian  follicle  cyst  is  uncertain.  The  cyst 
shoiikl  be  excised  and  the  defect  in  the  ovary  sutured. 

Tubo-ovarian  Cysts  may  occur  in  connection  with  any  variety  of 
ovarian  cysts,  but  are  especially  frequent  in  the  case  of  retention  cysts. 
They  may  follow  tubo-ovarian  abscess  (p.  1077). 

Cystadenomas  of  the  Ovary. — These  are  true  neoplasms.  Two  main 
varieties  are  recognized:  the  simple  (pseudomucinous)  cystadenoma,  and 
the  papuliferous  cystadenoma. 

Simple  Cystadenoma. — These  are  the  typical  "ovarian  cysts." 
Nowadays  they  rarely  reach  the  immense  size  formerly  encountered, 
when  the  tumor  not  infrequently  weighed  more  than  the  patient,  since 
operation  is  resorted  to  while  the  cysts  are  still  of  reasonable  size. 

Usually  only  one  ovary  is  affected.  The  cyst  originally  is  multi- 
locular,  but  the  smaller  cysts  frequently  coalesce  to  form  larger  com- 
partments, and  incomplete  partitions  may  be  the  only  evidence  of 
the  former  multilocular  state.  The  cyst  walls  are  hned  by  cylindrical 
epithelium  in  a  single  layer;  stratification  of  the  epithelium  is  rare  and 
may  indicate  a  malignant  tendency.  In  the  cyst  walls  are  found  down- 
growths  of  epithelium,  forming  simple  or  compound  gland  tubules. 
The  fluid  within  the  cysts  is  viscid,  glairy,  or  mucinous,  and  its  color 
varies  from  clear  yellow  to  turbid  or  brownish.  From  their  contents 
the  cysts  often  are  termed  pseudomucinous.  The  ovary  is  compressed, 
atrophied,  and  may  be  entirely  destroyed  by  the  pressure  of  the  cyst. 
The  two  most  frequent  complications  are  rupture  of  the  cyst,  and  torsion 
of  its  pedicle.  If  rupture  occurs  there  may  be  marked  shock,  but  this 
is  rare;  usuahy  the  fluid  is  absorbed,  and  temporary  polyuria  may  be 
noted;  in  other  cases  peritonitis  develops.  Occasionally  after  rupture 
portions  of  the  cyst  lining  become  engrafted  in  various  parts  of  the 
abdominal  cavity,  and  numerous  small  cysts  develop  (pseudomyxomu 
peritonei).  Torsion  of  the  pedicle  is  a  very  serious  accident,  which  occurs 
in  about  10  per  cent,  of  cases.  It  is  especially  frequent  in  dermoid  cysts 
(p.  1101).  The  symptoms  are  severe  pain,  shock,  and  sudden  increase 
in  size  of  the  tumor  (perhaps  previously  not  known  to  exist).  This 
sudden  increase  in  size  results  from  venous  obstruction  in  the  pedicle, 
causing  serous  and  bloody  transudation  in  the  cyst.  If  the  twist 
is  tight  enough,  gangrene,  with  slowly  developing  peritonitis,  may 
occur.    Prompt  operation  is  indicated  in  all  cases. 

Even  if  no  complications  occur,  the  clinical  course  of  an  ovarian 
cyst  is  invariably  toward  the  death  of  the  patient.  Ovarian  cysts 
grow  rapidly,  and  usually  life  is  terminated  witliin  comparatively 
few  years  unless  the  cyst  is  removed  by  operation. 

PAPiLLiFERors  Cystadexoma. — This  growth  frequently'  affects 
both  ovaries,  is  more  often  unilocular  than  multilocular,  often  develops 
between  the  layers  of  the  mesosalpinx,  and  rarely  attains  very  large 
size.  The  cyst  wall  is  lined  by  cylindrical-celled  epithehum,  usually 
not  stratified,  but  always  bearing  intracystic  papillomas.  The  con- 
tained fluid  is  thin  and  serous,  rarely  blood-tinged.  At  the  time  of 
operation  fuUy  50  per  cent,  of  these  tumors  are  already  carcinomatous, 


OVARIAN  AND  PAROVARIAN  CYSTS 


1009 


unci  it  is  liiglily  prol);iljle  tliiit  all  would  become  iiiuligiuuit  if  not 
removed.  The  continuous  growth  of  the  intracystic  papillomas  leads 
to  distention  of  the  cyst  and  fr(>([U(Mitly  causes  its  rupture,  whereupon 
the  growth  becomes  grafted  on  neighboring  structures  in  the  abdomen, 
and  ascites  frccpiently  results.  Seconddry  myxomatous  or  calcareous 
degeneration  may  occur. 


Fig.  1024. — Diagram  of  ovary  and  parovarium. 

Parovarian  Cysts. — The  parovarium  or  epoophoron  lies  in  the  broad 
ligament  between  the  ovary  and  Fallopian  tube.  It  is  formed  by 
the  remains  of  the  Wolffian  body  (Fig.  1024),  and  is  composed  of  a 
longitudinal  tube  (Gartner's  duct),  and  transverse  tubules  w^hich  run 
from  the  hilum  of  the  ovary  to  join  the  longitudinal  tube.  The 
Hydatid  of  Morgagni,  which  is  present  in  about  50  per  cent,  of  females, 
is  recognized  as  the  lateral  continuation  of  the  longitudinal  duct;  it 
enters  the  broad  ligament  on  its  anterior  surface  between  Fallopian  tube 
and  ovary.  Kobelt's  tubules  are  the  aberrant  tubules  of  the  Wolffian 
body  between  the  hydatid  of  Morgagni  and  those  tubules  which 
enter  the  hilum  of  the  ovary.  Any  of  these  tubular  structures  may 
become  the  seat  of  cystic  formation.  Cysts  arising  from  the  hydatid 
of  Morgagni  and  from  Kobelt's  tubules  usually  are  small,  are  attached 
to  the  lateral  border  of  the  broad  ligament  by  a  more  or  less  distinct 
pedicle,  and  seldom  produce  symptoms;  they  are  to  be  distinguished 
from  myxomatous  and  cystic  degeneration  of  the  fimbriae  of  the  Fal- 
lopian tube. 

The  typical  parovarian  cyst  forms  about  10  per  cent,  of  all  cases  of 
ovarian  cyst.  It  develops  and  spreads  within  the  folds  of  the  broad 
ligament  (hence  it  is  known  as  the  "broad  ligament  cyst"),  almost 
alwaj'S  is  unilocular,  grows  slowly,  and  seldom  attains  very  great  size. 
Its  contents  are  clear,  "like  spring  water,"  and  the  cyst  wall  is  lined 
with  a  single  layer  of  cylindrical  epithelium.  It  is  easily  distinguished 
from  an  ovarian  cyst  because  it  is  independent  of  the  ovary,  is  covered 
by  peritoneum,  possesses  a  double  layer  of  vessels  on  its  surface  (one 
belonging  to  the  peritoneum  and  the  other  to  the  cyst  w^all),  usually 
is  easily  enucleated  (rarely  forming  adhesions),  possesses  no  distinct 
pedicle,  and  almost  invariably  has  the  Fallopian  tube  stretched  out 
over  its  surface  at  some  distance  from  the  ovary. 


1100 


SURGERY  OF   THE  FEMALE  GENITALS 


Symptoms  and  Diagnosis  of  Ovarian  and  Parovarian  Cysts. — Few 
symptoms  are  present  unless  the  eyst  is  of  such  a  size  as  to  become 
impacted  in  the  pelvis,  or  unless  it  is  so  large  and  of  such  long  dura- 
tion as  to  have  induced  cachexia,  when  the  typical  fades  ovariana  is 
seen  (Fig.  1025).  In  most  cases  the  cyst  is  discovered  by  accident,  or 
the  woman  comes  to  the  surgeon  because  of  increase  in  size  of  the 
abdomen.  Ovarian  cysts  are  commonest  from  forty  to  fifty  years  of 
age. 


Fig.  1025. — Malignant  suppurating  ovarian  cyst  in  a  woman,  aged  fifty-seven  years; 
duration  of  illness  seven  j-ears.  Was  tapped  for  ascites  several  years  ago.  Tumor 
cystic  with  solid  masses;  abdominal  circumference,  with  patient  recumbent,  was  49 
inches.  Weight  149  pounds  (normal  weight  126  pounds).  Inoperable.  Episcopal 
Hospital. 

If  the  tumor  is  small  it  is  felt  as  a  smooth,  round,  tense,  fluctuating, 
movable,  and  usually  painless  tumor,  attached  to  the  uterus  by  a 
pedicle.  Differential  diagnosis  from  other  tubo-ovarian  lesions  depends 
chiefly  on  the  clinical  history. 

//  the  tumor  is  of  medium  size  (fetal  to  adult  head)  it  usually  rises 
out  of  the  pelvis  and  is  appreciated  as  an  abdominal  growth.  The 
diagnosis  must  be  made  from  uterine  fibroid  and  other  pelvic  tumors. 
The  cyst  lies  posterior  to  the  uterus  (a  distended  bladder  lies  in  front), 
and  it  often  is  possible  to  determine  that  the  uterus  is  of  normal  size. 
In  most  cases  the  pedicle  of  an  ovarian  cyst  can  be  detected,  but  this 
may  require  abdomino-rectal  palpation,  while  one  assistant  draws 
the  uterus  down  into  the  vagina  by  a  tenaculum  and  another  assistant 
draws  the  tumor  as  far  as  possible  out  of  the  pelvis  into  the  abdomen. 
If  a  pedicle  is  absent  (intraligamentary  cyst)  the  distinction  from  a 
subperitoneal  fibroid  may  be  very  difficult,  depending  chiefly  on  the 
clinical  history. 

When  the  tumor  becomes  very  large,  ascites  is  the  chief  condition  which 
simulates  it.  But  in  ascites  there  usually  is  some  organic  cause  for 
the  condition,  and  the  latter  has  developed  suddenly;  the  abdomen 
is  flat  on  the  top  and  bulging  in  the  flanks;  its  outline  does  not  rise 
abruptly  from  the  pubis  as  is  the  case  in  ovarian  cyst  (Fig.  1025); 
the  umbilical  area  is  resonant,  the  navel  pouts,  and  there  is  shifting 
dulness  in  the  flanks. 


OVARIOTOMY  1101 

Dermoid  Cysts  (Teratomas)  develop  from  the  ^'crmiiial  cells  of  the 
ovary.  Under  this  term  are  classed  both  sini})Ie  dermoid  cysts,  which 
contain  only  normal  skin  products  (secretions  of  sweat  and  sel)aceous 
glands,  hair,  nails,  and  teeth),  and  coviylicated  dermoid  cysts,  in  which 
may  he  found  also  bones,  cartilage,  muscle,  and  other  more  or  less 
fully  formed  structures  (embryomas).  Dermoid  cysts  frequently 
art'cct  both  ovaries,  and  may  begin  to  grow  at  any  age  (often  in  children 
and  young  girls).  When  growth  begins  it  usually  is  rapid;  but  if  the 
cyst  remains  small  it  may  cause  no  symptoms  unless  it  becomes  infected 
or  undergoes  carcinomatous  change  (both  are  frecjuent  complications) 
and  may  last  for  a  lifetime.  Usually  the  cysts  are  adherent  and  should 
l)e  treated  as  if  malignant. 

Solid  Tumors  of  the  Ovary  are  comparatively  rare.  They  are 
frecjuently  bilateral.  The  most  important  are  the  malignant  tumors: 
the  carcinomas  clinically  resemble  the  papuliferous  cystadenomas;  in 
many  cases  they  are  secondar^•  to  carcinoma  elsewhere  (stomach, 
breast,  uterus,  liver,  etc.)  being  grafted  on  the  germinal  epithelium 
of  the  ovary  through  the  medium  of  the  omentum.  Blood-stained 
ascitic  fluid  is  frequently  present.  Sarcoma  usually  occurs  at  a  younger 
age.  Of  the  benign  tumors,  fibroma  is  most  often  encountered ;  it  may 
occur  at  an  early  age,  but  seldom  causes  sj^mptoms  except  from  its 
weight  or  from  pressure  if  impacted  in  the  pelvis. 

Treatment. — All  such  growths  should  be  removed,  unless  clearly 
inoperable. 

Ovariotomy. — This  is  the  classical  operation  for  the  removal  of  an 
ovarian  cyst  (Ephraim  IMcDowell,  1809).  If  the  cyst  is  so  small  as 
to  be  delivered  easily  through  an  ordinary  abdominal  incision,  the 
operation  resembles  that  described  as  oophorectomy^  or  salpingo- 
oophorectomy  (p.  1079) ;  the  tube  may  or  may  not  be  removed  with 
the  diseased  ovary.  But  in  cases  where  the  tumor  is  very  large,  the 
technique  of  the  operation  is  different.  A  hypogastric  paramedian  in- 
cision is  made,  and  the  peritoneal  cavity  opened;  if  the  cyst  is  thought  to 
be  malignant  (papuliferous  cystadenoma,  dermoid)  every  effort  should 
be  made  to  prevent  its  rupture;  these  cysts  seldom  are  immensely 
large,  and  usually  may  be  delivered  through  an  incision  of  moderate 
size.  In  every  case  of  malignancy  both  ovaries  should  be  removed. 
In  the  case  of  an  immense  cyst,  however  (usually  a  simple  cystadenoma) , 
it  is  best  to  tap  the  tumor  so  as  to  enable  it  to  be  removed  through 
an  incision  of  ordinary  size.  After  the  cyst  wall  is  exposed,  the  pre- 
senting surface  of  the  tumor  is  isolated  by  gauze  packs,  and  a  large 
blunt  pointed  cannula  (at  least  1  cm.  in  diameter)  with  rubber  tube 
attached,  is  thrust  into  an  avascular  area  of  the  cyst  wall,  and  the 
contents  are  removed  by  syphonage.  If  the  cyst  is  multilocular  it 
may  be  necessary  to  tap  several  loculi;  usually  a  sufficient  number 
may  be  reachcfl  from  the  interior  of  that  first  emptied  without  with- 
drawing the  cannula.    As  the  cyst  walls  collapse  they  are  to  be  drawn 

'  This  of  course  is  a  more  correct  term  etymologicaUy,  but  long  usage  sanctions 
the  use  of  the  term  ovariotomy  for  the  tyjjical  operation  for  large  ovarian  cysts. 


1102  SURGERY  OF   THE  FEMALE  GENITALS 

into  the  wound  with  volselhim  forceps,  and  an  assistant  is  to  make 
pressure  on  the  flanks,  so  as  to  prevent  leakage  into  the  abdominal 
cavity.  When  the  entire  tumor  has  been  withdrawn  the  pedicle 
comes  into  view.  If  there  are  adhesions,  the  operation  is  much  more 
difficult,  and  careful  dissection  may  be  required  to  free  the  tumor  from 
omentum,  mesentery,  intestine,  etc.  When  the  pedicle  has  been 
brought  into  view,  it  should  be  caught  in  strong  crushing  forceps, 
and  ligated  by  transfixion  in  the  groove  thus  made.  The  pedicle 
usually  is  composed  of  broad  and  round  ligaments.  Fallopian  tube, 
and  infundibulo-pelvic  ligament.  Great  care  should  be  taken  to  see 
that  hemostasis  is  complete;  when  they  can  be  identified  the  ovarian 
and  utero-ovarian  arteries  should  be  tied  separately.  Finally  the 
stump  of  the  infundibulo-pelvic  ligament  should  be  united  to  the 
stump  of  the  tube,  and  denuded  areas  should  be  covered  by  peri- 
toneum.   Before  closing  the  abdomen  always  examine  the  other  ovary. 

If  the  intestines  are  carefully  protected  from  exposure  and  the 
patient's  bodily  heat  maintained,  the  operation  is  attended  by  very 
little  shock.    The  mortality  in  expert  hands  is  below  5  per  cent. 

Fibroids  of  the  Uteras. — These  tumors  are  fibro-myomas;  those 
with  an  excess  of  fibrous  tissue  justly  merit  the  term  fibroids,  but  in 
general  this  term  and  myoma  or  fibromyoma  are  used  indiscriminately, 
regardless  of  the  amount  of  fibrous  tissue  present  in  the  tumors.  The 
tumors  usually  are  multiple,  and  spring  from  the  uterine  wall,  prob- 
ably, it  is  believed,  from  the  walls  of  bloodvessels.  Thej'  occur  with 
greatest  frequency  in  the  body  of  the  uterus,  fibroids  of  the  cervix 
being  comparatively  rare.  By  some  the  affection  is  considered  a  wide- 
spread disease,  with  one  of  its  local  manifestations  in  the  uterus;  and 
they  explain  the  frequently  accompanying  myocardial  changes  in  this 
way.  Some  authorities  teach  that  the  tumors  always  have  a  congenital 
origin;  it  is  undisputed,  however,  that  they  seldom  begin  to  produce 
symptoms  or  are  discovered  until  well  into  the  child-bearing  period, 
from  thirty-five  to  forty-five  years  of  age.  A  woman  with  fibroids 
usually  is  sterile,  and  it  is  disputed  whether  sterility  is  to  be  regarded 
as  a  cause  or  a  result  of  the  existence  of  fibroids.  If  pregnancy 
occurs  it  is  very  apt  to  result  in  abortion  or  miscarriage.  Fibroids 
are  especially  common  in  the  negro  race. 

The  tumors  begin  as  interstitial  growths,  within  the  walls  of  the 
uterus ;  they  may  remain  in  the  uterine  wall  even  when  attaining  very 
large  size,  but  usually  they  tend  to  push  their  way  through  to  the 
sub  peritoneal  or  the  submucous  surface  of  the  uterus.  In  many  cases 
tumors  are  found  in  all  three  locations.  They  may  present  beneath 
the  peritoneum  or  mucosa  as  sessile  gro^-ths,  but  not  infrequently 
a  pedicle  forms.  Then  the  tumor,  if  subperitoneal,  may  become  adher- 
ent to  neighboring  abdominal  structures,  as  the  result  of  attacks  of 
congestion  and  inflammation  from  torsion  of  the  pedicle;  and  in  rare 
instances  these  secondary  adhesions  may  become  so  firm  that  the 
pedicle  ruptures  and  the  migrated  fibroid  continues  to  receive  its 
nourishment    through    the    adhesions    alone.      Submucous    fibroids 


FIBROIDS  OF   THE   UTERUS 


1103 


frof(n(Mitly  tlovelop  {)e(lides,  and  present  in  tlie  uterine  eavity  or  pro- 
trude from  the  eervix  in  the  form  of  poJyjd.  Usually  only  one  polypus 
is  i)resent,  si)ringin<;'  from  the  eervix  or  near  it,  and  mostly  fibrous  in 


Fig.  102G. — Fibroids  of  the  utirn.<,  siiln.ci 
years.     (See  Fig.  1U27.) 


f lineal  and  interstitial;  age  fifty-three 
Episcopal  Hospital. 


Fig.  1027. — Uterine  fibroids,  specimen  shown  in  Fig.  1026  sectioned,  exposing  inter- 
stitial growths,  one  of  which  has  undergone  cystic  degeneration.  Note  also  carcinoma 
of  the  cervix,  with  its  crater-like  excavation;  a  rare  complication  of  fibroid  tumors. 
Episcopal  Hospital. 


1104 


SURGERY  OF   THE  FEMALE  GENITALS 


structure.  If  a  polypus  springs  from  the  fundus  of  the  uterus,  the 
uterine  wall  becomes  thinned  at  the  point  of  attachment,  and  inversion 
of  the  uterus  may  occur. 

Symptoms. — In  many  cases  no  symptoms  whatever  are  produced 
until  the  tumors  become  so  large  as  to  cause  pressure  effects.  Among 
the  most  usual  of  these  are  vesical  irritability,  hemorrhoids  and  inter- 
ference with  defecation,  pain  in  the  sacrum  and  coccyx,  varicose 
veins  or  edema  from  interference  with  the  circulation  of  the  lower 
extremities,  renal  disturbances  from  pressure  on  the  ureters,  etc. 
Interstitial  grouihs  may  cause  no  noticeable  change  in  the  form  of  the 
uterus,  though  it  may  be  much  larger  than  normal,  and  the  depth 
of  its  cavity  will  be  increased;  but  a  sound  should  not  be  introduced 
without  due  consideration,  particularly  until  the  possibility  of  preg- 
nancy has  been  absolutely  eliminated.     Dysmenorrhea  is  present  in 


Fig.  1028. — Prolaj'-'  :  -  .  iiniinus  fibroid  :?iranL'ul  ;;  -i  \sith  complete  inversion 
of  vagina — uterus  not  invtrted.  Age  forty-three  years.  Had  normal  childbirth  two 
j'ears  ago,  and  no  symptoms  from  fibroid  until  prolapse  occurred,  twenty-three  hours 
before  operation  (vaginal  hysterectomy).  Death  from  peritonitis  five  days  after 
operation.    Episcopal  Hospital. 

some  cases  of  interstitial  growi;hs.  Subperitoneal  growths  usually 
may  be  recognized  by  bimanual  palpation;  they  may  be  of  various 
sizes  and  shapes,  but  are  attached  to  the  uterus,  move  with  it,  and 
usually  are  high  in  the  pelvis,  not  in  the  position  where  pus  tubes 
are  found;  unless  the  tumor  is  very  large,  or  impacted  in  the  pelvis, 
the  tumor  is  not  fixed.  Submucous  grouihs  are  particularly  charac- 
terized by  profuse  and  prolonged  menstrual  bleeding;  intermenstrual 
hemorrhage  is  rare,  though  bleeding  may  last  from  one  period  to  the 
next  and  continue  through  this;  then  an  intermission  may  occur  until 
the  normal  time  for  the  occurrence  of  the  next  menstruation  which 
will  also  be  unduly  prolonged.  Anemia  is  a  frequent  result  and  may 
be  severe.  Sometimes  submucous  tumors  may  be  detected  by  the 
introduction  of  a  finger  into  the  os,  which  frequently  is  patulous. 
Attacks  of  colicky  pain  may  be  caused  by  efforts  of  the  uterus  to 
force  the  tumor  through  the  cervix.     Complications:   Occasionally  a 


FIBROIDS   OF    rilF    rTERl'S  llOo 

larjje  sul)niuc()iis  fibroid  proldp.sr.s-  tlir()iiji;li  the  \;i^iiia,  and  may  cause 
invcrjfion  of  tliis  structure  or  eveu  of  the  uterus  itself.  Sfranyulation 
of  the  i)r()hii)sed  fibroid  may  occur,  resultiufj  in  (/angrene,  a  very 
serious  compHcatiou  ( Fi^^  1()2S).  Fil)rous  j)ol>pi  are  less  serious  than 
Iar<i-er  myomatous  sul)uuicous  tuuiors,  rarely  causing  alarming  hleed- 
inj;.  Vet  the  presence  of  any  submucous  growth  predisposes  to  infec- 
tion of  the  endometrium,  and  this  readily  extends  to  the  tubes,  so  that 
hy(lrosali)inx,  as  already  noted  (p.  1077),  is  a  frequent  complication. 
Or  infection  may  spread  directly  to  the  tumor  mass,  causing  a  very 
serious  form  of  septic  metritis. 

Diagnosis. — This  is  made  from  attention  to  the  history  of  the  case, 
from  observation  of  the  symptoms,  and,  most  important  of  all,  from 
the  ph\sical  examination.  It  is  especially  important  in  every  case 
to  exclude  the  presence  of  pregnane}/:  a  large  interstitial  m>'oma,  par- 
ticularly if  softened  as  the  result  of  passive  congestion  with  edema, 
may  so  closely  simulate  pregnancy  as  to  deceive  even  the  elect.  Too 
much  reliance  should  not  be  placed  on  the  history  in  such  cases,  if 
it  is  impossi})le  to  corroborate  the  patient's  tale;  many  women  would 
be  pleased  to  be  relieved  of  a  pregnancy  by  hysterectomy,  and  are 
wilfully  deceitful.  Usually,  however,  in  pregnancy  the  cervix  is  softer, 
the  uterus  feels  more  cystic,  the  menses  are  absent,  and  always  (if 
the  policy  of  "waiting  and  watching"  is  followed)  indisputable  signs 
of  pregnancy  will  declare  themselves  in  time.  An  ovarian  cyst  may 
closely  resemble  a  fibroid  of  the  uterus  if  it  is  \'ery  tense,  and  particu- 
larly if  intraligamentary;  in  some  cases  nothing  short  of  an  exploratory 
operation  will  clear  the  diagnosis.  In  the  case  of  pyosalpin.v  the  history 
is  dift'erent ;  the  mass  usually  is  posterior  to  the  uterus  and  fixed ;  there 
is  more  leucorrhea  than  in  fibroids,  and  menstruation  is  irregular 
rather  than  prolonged  or  profuse.  The  diagnosis  from  carcinoma 
and  other  malignant  tumors  rarely  is  difficult. 

Adenomyoma  of  the  uterus  occurs  in  5  per  cent,  or  more  of  cases. 
The  glandular  elements  are  derived  either  from  the  endometrium 
(Cullen,  1903),  or  from  remnants  of  the  Wolffian  body  in  the  walls 
of  the  uterus  (von  Recklinghausen,  1896).  The  tumors  frequently 
are  infiltrating  in  character,  but  occasionally  subperitoneal  more  or 
less  encapsulated  growths  develop,  or  even  polypi.  Cyst  formation 
is  the  only  form  of  degeneration  which  is  common.  The  symptoms 
are  much  the  same  as  in  cases  of  ordinary  fibroids,  and  the  diagnosis 
seldom  is  made  except  in  the  pathological  laboratory.  The  existence 
of  this  ^'ariety  of  myoma  may  be  suspected,  however,  if  the  tumor 
is  very  adherent,  and  particularly  if  it  is  cystic  and  the  contents  of 
the  cysts  are  chocolate  colored  (menstrual  fluid).  The  proper  treat- 
ment is  hysterectomy. 

Prognosis. — The  prognosis  of  uterine  fibroids  is  not  good.  Until 
some  symptoms  are  produced,  the  growths  often  pass  undiscovered. 
But,  when  symptoms  of  any  kind  once  have  appeared,  it  is  rare  for 
the  patient  ever  again  to  be  free  from  discomfort.  The  menopause 
is  indefinitely  deferred,  and  the  tumor  usually  continues  to  grow. 
70 


1106  SURGERY  OF   THE  FEMALE  CEXITAL.^ 

Not  to  mention  various  degenerations  (calcareous,  myxomatous, 
cystic,  hyaline,  malignant*  of  the  tumors,  which  occur  in  about  20 
per  cent,  of  cases,  and  the  ever-threatening  degeneration  of  the 
cardiac  muscle,  which  is  almost  inevitable,  the  woman  is  subject 
to  the  dangers  of  hemorrhage,  miscarriage,  sepsis,  inversion  of  the 
uterus,  etc. 

Treatment  of  Uterine  Fibroids. — We  liear  reports  lately  of  favoraV)le 
results  secured  l^y  .r-ray-  and  radium  treatment,  just  as  some  years  ago 
much  was  heard  of  the  electric  treatment  advocated  by  Apostoli,  and 
even  before  that  time  of  the  curative  \alue  of  ergot.  Whether  these 
new  departures  will  prove  more  lasting  than  their  predecessors  time 
alone  can  show;  but  for  the  present  and  immediate  future  at  least,  the 
treatment  advised  and  practised  by  rational  surgeons  is  operative. 
The  tumors  should  he  removed.  In  some  comparatively  young  women 
who  are  anxious  to  l)ear  children,  it  may  be  justifiable  to  remove  the 
individual  tumors,  leaving  the  main  bulk  of  the  uterus  intact.  This 
is  especially  the  case  when  a  pol\-pus  is  present,  without  other  demon- 
strable growths.  Polypi  may  be  removed  through  the  vagina  after 
the  division  of  the  |)edicle  by  scissors  or  by  formal  excision  from  the 
uterine  wall.  Temporary  division  of  the  cervix  may  be  necessary. 
Bleeding  from  the  stump  of  the  polyp  rarely  is  severe  and  may  be 
controlled  by  packing  if  suture  is  impossible.  Isolated  subperitoneal 
growths  may  be  removed  by  excision  and  enucleation  through  an 
abdominal  wound:  the  operation  is  known  as  myomectomy.  The  objec- 
tions to  it  (largely  theoretical)  are  that  other  tumors  almost  surely 
are  overlooked  and  will  subsequently  give  rise  to  trouble;  that  even 
should  pregnancy  follow  it  is  very  apt  to  be  terminated  prematurely; 
and  that  should  pregnancy  continue  to  term,  grave  complications 
may  arise  during  parturition  or  the  puerperium  from  other  fibroids 
which  have  grown  during  the  pregnancy.  But  in  a  small  proportion 
of  cases,  carefully  selected,  the  operation  is  of  value. 

In  the  great  majority  of  cases  removal  of  the  uterus  {hysterectomy) 
is  preferable.  This  may  be  accomplished  by  the  vaginal  route  (raginal 
hyst£rertomy)  if  the  uterus  is  small;  but  in  most  cases  the  abdominal 
ojjeration  is  required.  If  the  uterus  is  amputated  above  the  cervix 
the  operation  is  known  as  .nipraraginal  hysterectomy;  if  the  cervix  also 
is  removed  the  proper  term  is  pan-hysterectomy.  In  most  cases  the 
tubes  and  ovaries  are  removerl  also  {complete  supraAaginal  or  pan- 
hx'sterectomy  i . 

Abdominal  Hysterectomy. — The  fundus  of  the  uterus  is  drawn  through 
the  abdominal  wound  by  volsellum  forceps,  and  one  broad  ligament 
is  exposed  by  flrawing  the  tumor  well  to  the  other  side.  Clamps 
may  then  be  applied  to  both  sides  of  the  proposed  section,  leaving 
the  adnexa  attached  to  the  uterus  if  they  are  diseased  (Fig.  1029). 
In  many  cases  it  is  simpler  to  ligate  the  ovarian  vessels  at  once, 
applying  clamps  only  to  the  uterine  side  of  the  broad  ligament. 
Hemorrhage  being  thus  controlled,  the  broad  ligament  is  divided 
with  scissors  down  to  the  level  of  the  cervLx,  but  not  far  enough  to 


IIYSTEHECTOMY  11(1- 

wound  X\w  uterine  jirtery,  wliicli  lias  not  yet  hccn  secured.  The  roinid 
ligament  is  tlien  Heated  close  to  the  uterus,  and  di\ided  hetween  the 
ijiiaturc  and  uterus.  The  tumor  is  then  pulled  to  the  patient's  other 
side,  and  the  broad  and  round  ligaments  are  divided  as  on  the  first  side. 
'J'his  frees  the  uterus  so  that  in  most  cases  the  cervix  can  he  drawn 
up  into  the  ahdominal  wound.  The  tumor  is  then  turned  backward, 
and  an  incision  is  made  from  one  round  ligament  to  the  other  some- 
what above  the  vesical  reflection  of  peritoneum.  The  peritoneal  flap 
thus  formed  is  pushed  away  from  the  cervix  by  gauze  dissection, 
until  at  the  sides  of  the  cervix  the  uterine  vessels  are  exposed.    These 


Fig.  1029. — Diagram  to  show  technique  of  abdominal  panhysterectomy:  on  the 
right  of  the  pictuie  the  left  ovary  and  tube  are  being  removed  with  the  uterus;  the 
right  ovary  is  not  being  lemoved.  Ligatures  have  been  placed  on  the  ovarian  and 
uterine  arteries  and  on  the  round  ligaments  on  both  sides,  and  the  tissues  close  to  the 
uterus  have  been  clamped.  The  anterior  vaginal  fornix  has  been  opened  exposing  the 
cervix. 


are  clamped  close  to  the  uterus  and  ligated  not  more  than  half  an 
inch  distant;  the  ureter  crosses  under  the  uterine  artery  about  three- 
quarters  of  an  inch  (2  cm.)  distant  from  the  cervix.  The  uterine  vessels 
are  then  divided  on  both  sides,  between  clamp  and  ligature.  The 
uterus  is  then  turned  well  forward  over  the  pubes,  and  an  incision 
is  made  across  its  body  above  the  pouch  of  Douglas,  from  one  broad 
ligament  attachment  to  the  other;  and  the  jieritoneal  flap  thus  formed 
is  pushed  downward  by  gauze  dissection.  Finally  the  cervix  is  cut 
through  with  scissors  in  funnel  shape,  and  the  uterus  is  removed. 
The  cervical  canal  is  then  closed  with  catgut  sutures,  and  the  stumps 


1108 


SURGERY  OF   THE  FEMALE  GENITALS 


of  the  round  and  broad  ligaments  are  sutured  to  it,  so  as  to  support 
it  in  proper  position.  Then  the  peritoneal  flaps  front  and  back  are 
united  over  the  cervical  stump,  closing  in  all  areas  denuded  of  peri- 
toneum.   In  most  cases  the  abdomen  is  closed  without  drainage. 

If  it  is  desired  to  remove  the  cervix  also,  the  dissection  must  be  carried 
a  little  deeper;  then  the  Aaginal  vault  is  divided.  The  surgeon  must 
look  for  bleeding  from  the  vaginal  arteries  and  secure  a  dry  field 
before  proceeding.  Finally,  the  stumps  of  the  round  and  broad 
ligaments  are  implanted  into  the  vaginal  vaidt. 

Vaginal  Hysterectomy. — This  is  suitable  only  in  cases  where  the 
tumor  is  small,  and  the  vagina  sufficiently  relaxed.  A  self-retaining 
speculum  is  used  (Fig.  1002),  and  the  cervix  is  closed  by  sutures  or 
by  a  double  tenaculum  forceps,  and  drawn  outside  the  vulva.  An 
incision  is  next  made  all  around  the  cervix,  through  the  mucosa; 
the    incision   in   the   anterior    cul-de-sac   is   deepened,   pushing    the 


Fig.  1030. — Diagram  of  vaginal  hysterectomy,  showing  application  of  clamps 
to  the  broad  ligaments. 

bladder  wall  and  with  it  the  ureters  well  upward  and  forward, 
until  the  peritoneal  cavity  is  opened.  A  finger  is  then  inserted 
into  the  pelvic  cavity  and  passed  behind  the  cervix,  and  on  this 
finger  as  a  guide  the  posterior  vaginal  cid-de-sac  is  further  incised 
until  the  peritoneal  pouch  of  Douglas  is  opened.  Gauze  is  then 
packed  into  this  opening  to  keep  the  intestines  from  prolapsing 
into  the  wound.  Any  bleeding  is  easily  controlled  by  hemostats. 
If  the  tumor  is  not  too  large,  the  fundus  of  the  uterus  may  now  be 
hooked  down  by  the  finger  and  brought  out  through  the  incision  in  the 
anterior  vaginal  cul-de-sac.  If  this  can  be  accomplished  the  broad 
ligaments  may  then  be  ligated  from  their  ovarian  border  downward 
to  the  cervix,  as  in  supravaginal  hysterectomy.  If  the  fundus  of  the 
uterus  cannot  be  deli^Tred  in  this  way,  the  broad  ligaments  are  clarnped 
from  below  upward,  not  more  than  half  an  inch  distant  from  the 
cervix,  removing  the  tubes  and  ovaries  also  if  they  are  diseased  (Fig. 


CAiicixoMA  or  riiK  iTh'h'rs  1109 

lOlU)).  Thv  hroiid  li<;;iin('iits  arc  then  cut  tliroiijili  hctweeii  tlic  clamps 
and  the  uterus;  and  the  iKTitoneum  is  closed,  the  ^auzc  pack  heiiij; 
removed  as  the  last  peritoneal  suture  is  tied.  After  carefully  lif^ating 
the  broad  liiianients,  their  stumi)s  arc  sutured  to  the  vaginal  \ault. 
A  uau/.c  drain  is  left  in  the  \a^ina.  The  o])cration  mav  he  done  also 
without  ligatures,  leaving  the  clamps  on  the  broad  ligaments  for  se^■eral 
days.  Si)ecial  clamps,  with  detachable  handles,  hnvv  been  de\ised 
for  this  ])ur|)ose. 

Carcinoma  of  the  Uterus.  This  is  exceedingly  common,  especially 
in  the  cer\i\.  Only  al)out  o  to  10  per  cent,  of  cases  occur  in  the  body 
of  the  uterus.  In  the  cervix  the  growth  almost  always  is  a  squamous- 
celled  ejMthelioma,  though  carcinoma  of  the  glandular  type  (adeno- 
carcinoma) sometimes  occurs;  while  in  the  body  of  the  uterus  the 
tumor,  with  a  very  few  rare  exce])ti()ns,  is  an  adenocarcinoma.  Most 
patients  are  in  the  fourth  decade  of  life,  approaching  or  past  the  meno- 
pause; almost  all  have  borne  children,  and  many  have  had  lacerations 
of  the  cer\ix  which  have  not  received  proper  treatment. 

Carcinoma  of  the  Cervix  occurs  in  two  forms:  (1)  as  an  evertiity,  vef/e- 
tat'uHj,  proliferating,  or  cauliflower-like  growth;  or  (2)  as  an  invert lug, 
infiltrating,  and  contracting  growth.  At  an  early  stage  of  the  disease 
these  two  types  are  quite  distinct,  but  later  the  carcinomatous  tissue 
tends  to  become  necrotic,  and  when  sloughs  have  been  shed  the  cervix 
is  represented  only  by  a  crater-like  cavity  filled  with  purulent  debris 
(Fig.  1027).  The  everting  type  is  more  easily  recognized  at  an  early 
date,  owing  to  the  papillary  excrescences  w^hich  form;  wdiereas  in  the 
infiltrating  type  very  extensive  invasion  of  the  cervical  tissues  may 
occur  before  there  is  much  alteration  in  the  appearance  of  its  vaginal 
surface. 

Extension  occurs  to  all  surrounding  tissues,  but  in  no  definite  order. 
The  bases  of  the  broad  ligaments  frequently  are  invaded  early,  so 
that  the  uterus  becomes  fixed;  the  ureters  are  surrounded  and  may 
become  compressed  by  the  growth;  the  pelvic  lymphatics  up  to  and 
even  beyond  the  bifurcation  of  the  aorta  are  invaded ;  sometimes  exten- 
sion to  the  inguinal  lymphatics  occurs;  the  growth  extends  locally 
into  the  vaginal  vault,  and  the  bladder  and  even  the  rectum  may  be 
infiltrated,  so  that  late  in  the  disease  distressing  vesico-vaginal  fistula^ 
(rarely  recto-vaginal)  may  form.  In  most  cases  the  uterine  body 
remains  free  of  disease,  the  carcinomatous  growth  rarely  extending 
abo^•e  the  level  of  the  internal  os. 

Symptoms. — These  usually  are  absent  or  are  overlooked  until  the 
disease  is  quite  far  advanced;  only  from  10  to  20  per  cent,  of  patients 
applying  for  treatment  are  susceptible  of  cure.  The  most  important 
symptom,  and  usually  the  earliest,  is  bleeding,  especially  intermenstrual 
or  occurring  after  the  menopause,  l^sually  this  bleeding  occurs  spon- 
taneously, and  is  moderate  or  apparently  insignificant  in  amount; 
it  may  follow  coitus  or  defecation;  occasionally  it  is  profuse  and  pros- 
trating. Such  a  sudden  and  alarming  hemorrhage  almost  always  is 
due  to  carcinoma  and  not  to  fibroids.    The  bleeding  is  painless  as  a 


niO  SURGERY  OF   THE  FEMALE  GENITALS 

rule,  and  unless  the  woman  notes  its  occurrence  and  submits  to  \agiual 
examination,  she  may  go  along  for  months  before  anything  further 
occurs  to  call  attention  to  her  condition.  There  may  he,  indeed 
there  usually  is,  a  certain  amount  of  Icitcorrheu;  and  the  serous,  watery, 
or  blood-stained  character  of  this,  and  at  a  later  period  its  fetor,  ma\' 
arrest  her  attention.  Pain  is  a  late  and  unimportant  symptom;  it 
rarely  is  severe  until  the  sacral  plexus  is  in\'()lved  and  the  tumor 
entirely  inoperable. 

The  disease  may  thus  be  divided  clinically  into  three  stages:  (1)  the 
stage  of  occasional  hemorrhage;  (2)  the  stage  of  gradual  decline  of  health, 
ivith  fetid  leiicorrhea;  and  (8)  the  inoperable,  hopeless  stage,  with  excru- 
ciating pain,  and  disgusting  odor,  the  patient's  condition  being  loath- 
some to  herself  and  all  about  her.  The  a\'erage  duration  of  the  disease 
from  first  symptoms  to  death  averages  from  fifteen  to  twenty  months. 

Carcinoma  of  the  body  of  the  uterus  presents  the  same  symptoms, 
but  they  develop  at  a  much  later  period,  and  are  not  attended  by  any 
definite  physical  signs,  except  slight  enlargement  of  the  uterus.  It  is 
much  more  frequent  in  women  who  haAe  borne  no  children  than 
carcinoma  of  the  cervix. 

Diagnosis. — Every  woman  whose  symptoms  suggest  the  mere  pos- 
sibility of  the  disease  should  be  submitted  to  a  competent  surgeon 
for  a  most  painstaking  vaginal  examination;  any  alteration  in  the 
cervix,  especially  if  bleeding  is  easily  aroused,  should  be  regarded  as 
suspicious,  and  a  section  should  be  taken  for  microscopic  study. 
This  is  easily  done  after  swabbing  the  cervix  inside  and  out  with  10 
per  cent,  eucain  solution;  the  section  (removed  with  knife  or  scissors) 
should  extend  from  the  cervical  canal  into  apparently  healthy  tissue, 
and  should  be  submitted  to  a  pathologist  for  prompt  report.  If  a 
carcinoma  of  the  uterine  body  is  suspected,  the  curette  should  be 
used,  and  the  scrai)ings  mounted  and  examined  histologically. 

Treatment. — A  radical  operation,  similar  in  scope  to  that  practised 
in  cases  of  carcinoma  of  the  breast,  and  involving  removal  of  the  pelvic 
lymph  nodes  and  connective  tissues  in  one  mass  with  the  diseased 
uterus,  was  systematized  in  1S95  by  Ries,  elaborated  by  Sampson, 
and  popularized  by  ]\Iackenrodt,  Wertheim,  and  others;  })ut  while 
in  theory  this  procedure  is  correct,  it  is  found  that  the  immediate 
mortality  even  in  the  hands  of  skilled  gynecological  operators  is  about 
25  per  cent.  An  inexperienced  surgeon  will  not  be  able  to  do  a  com- 
plete operation,  and  in  his  attempt  to  be  ultra-radical  probably  will 
do  more  harm  than  good.  ]Many  investigators  claim  that  a  truly 
radical  operation  is  impossible,  and  point  out  that  autopsies  have 
shown  that  whenever  carcinomatous  lymph  nodes  were  removed  at 
operation,  others  were  overlooked.  It  seems  to  me  that  we  must 
look  upon  these  radical  methods  as  still  upon  trial,  and  only  to  be 
attempted  by  exceptionally  skilled  and  experienced  operators  in 
carefully  selected  cases.  JVhen  the  uterus  is  not  fixed  its  removal  by 
the  ordinary  method  of  pan-hysterectomy  (p.  1106),  paying  special 
attention  to  wide  excision  of  the  vaginal  vault,  but  without  attempts 


CIlOh'lO-l'H'I'I'llh'LIOMA    MALKISUM  1111 

to  dissect  tlu'  |)i'l\ic  lyinpli  nodes,  is  :iii  operjitioii  not  attended  hy  an 
unjustiliaMe  |)riniary  mortality;  and  inan\  patients  so  treated  will 
he  restored  temporarily  to  health  and  enjoyment  of  life;  anil  ulien 
recurrence  or  metastasis  takes  jjlaee,  as  it  almost  surely  will,  the 
condition  will  he  much  less  distrossiiifi;  than  if  no  operation  had 
heen   performed. 


# 


\ 


Fig.  1031. — Cborio-epithelioma  maligmim,  in  a  patient  aged  forty-two  years.  Diag- 
nosis made  from  microscopical  examination  of  scrapings  from  endometrium  ten  days 
after  an  abortion.     Immediate  hysterectomy.     Episcopal  Hospital. 

When  the  uieriis  is  fixed,  and  its  removal  appears  impossible,  the 
patient's  comfort  may  be  greatly  promoted  and  her  life  prolonged 
by  scraping  away  the  cervical  growth  with  a  curette,  and  cauterizing 
its  base  thoroughly  with  the  actual  cautery.  This  palliative  operation 
may  be  repeated  every  few  months,  and  may  be  used  in  cases  of  recur- 
rence after  hysterectomy.  It  deserves  to  be  employed  with  more 
enthusiasm  than  is  usually  accorded  to  ])alliative  operations. 

Chorio-epithelioma,  or  Deciduoma  Malignum  (Sanger,  188S),  is 
an  exceedingly  malignant  tumor  growing  in  the  body  of  the  uterus 
after  pregnancy.  The  pregnancy  frequently  is  terminated  before 
term,  and  the  most  favorable  cases  are  those  in  which  the  diagnosis 
is  made  by  the  pathologist  from  examination  of  retained  tissues 
removed  in  such  cases  (Fig.  lOl^l).  Such  examination  never  should  be 
neglected.  The  tumor  probably  arises  from  the  chorionic  and  not 
from  the  decidual  tissues;  it  behaves  like  the  most  malignant  types 
of  sarcoma,  giving  early  venous  metastasis,  especially  to  the  lungs 
(78  per  cent.)  and  vagina  (54  per  cent.)  (l)orland).  Vaginal  growths 
may  be  the  only  evidences  of  the  disease.  The  chief  symptoms  resemble 
those  of  uterine  carcinoma,  namely  bleeding,  and  watery  leucorrhea. 
The  proper  treatment  is  pan-hysterectomy,  if  the  diagnosis  is  made 


1112 


SURGERY  OF   THE  FEMALE  dENITALS 


before  distant  metastases  occur.  Removal  of  vaginal  growths  in 
cases  where  the  uterus  appears  free  from  the  disease,  has  occasionally 
proved  successful. 


Fig.  1032.- 


-Carcinoma  of  vulva;  age  forty-five  years;  duration  eight  months. 
Pennsylvania  Hospital. 


Carcinoma  of  the  Vulva  is  not  very  rare  (Fig.  1032).  Extension 
occurs  to  the  inguinal  lymph  nodes,  and  radical  operation  requires 
the  extirpation  of  these  on  both  sides,  the  technique  being  similar 
to  that  adopted  in  cases  of  carcinoma  of  the  external  genitals  of  the 
male. 


iM)i:.\. 


Ahi)()Mi;.\,  gunshot  wounds,  191 
treatment,  845 
injuries,  840 

operation,  842 
operations,  818 
stab  wounds,  844 
Abdominal  incisions,  818 

operation,  after-treatment,  825 
preparation  of  jjatient,  823 
technique,  823 
section,  818 
surgery,  802 
tumors,  diagnosis,  953 
wall,  contusion,  840 
rupture,  840 
Ablation  of  breast,  721 
Abortion,  tubal,  1090 
Abrasions,  159 
Abscess,  26,  47 
acute,  47 

treatment,  50 

Hilton's  method,  51,  G75 
alveolar,  657 
appendicular,  858 

treatment,  860 
axillary,  729 
Bezold's,  631 
bone,  437 
brain,  579 
Brodie's,  437 
chronic,  47 
cold,  47,  79 

treatment,  483 
digital,  279  . 
gluteal,  607 
ihac,  607,  813 
ischiorectal,  607,  903 
liver,  936 
lumbar,  607 
lung,  748 
mammary-,  700 

chronic,  701 
metastatic,  73 
neck,  675 
ovary,  1078 
palmar,  279 
pancreas,  946 
pelvic,  813,  1077,  1096 

extraperitoneal  incision,  109(5 
vaginal  puncture,  1096 
l)elvirectal,  904 


Abscess,  peri-anal,  903 

pcrinei)iMic,  977 

])erit()nsillai-,  (563 

j)eri-urethral,  1027 

phlegmonous,  47 

pointing,  48 

prostate,  1028 

psoas,  607 

residual,  805 

peritoneal,  813 

retropharyngeal,  (506 

scrofulous,  47 

secondary,  73 

spleen,  955 

subcranial,  578 

submammary,  702 

subpectoral,  730 

subphrenic,  813 

subscapular,  731 

tongue,  647 

tubo-ovarian,  1077 

vulvo-vaginal,  1071 
Acapnia,  172 
Achillodynia,  267 
Achondroplasia,  417 
Acne  hyper trophica,  620 
Acromegaly,  424 

Acromioclavicular  dislocation,  394 
Actinomycosis,  84 
Acupressure,  229 
Acupuncture,  142 
Adamantinoma,  112 
Adenitis,  269 

cervical,  674 
Adenocarcinoma,  125 
Adenoma,  119 

of  breast,  713 

of  rectum,  913 
•Adenomatosis,  119 
Adenomyoma  of  uterus,  1105 
Adenosarcoma,  106 
Adherent  prepuce,  1046 
Adhesions,  peritoneal,  814 
Ainhum,  64 
Air-hunger,  227 

Air  passages,  foreign  bodies,  665 
operations,  668 
surgery,  6(35 

sinuses,  operations,  655 
Albert-Lembert  suture,  829 
Albert's  disease,  267 
Albumosuria  (Bence-Jones),  113 
Alexander's  operation,  1086 


1114 


INDEX 


Alexins,  23 

Alimentary  glycosuria,  'J4S 
Allis's  sign,  364 
Alveolar  abscess,  657 

border,  tumors,  660 
Amebic  dysentery,  S95 
Amicrobic  meningitis,  579 
Amputating  knives,  195 
Amputations,  192 

ankle-joint,  211 

arm,  207 

Ashhurst's,  212 

Billroth's,  216 

breast,  710 

Chopart's,  211 

c'inematoplastic,  202 

circular  method,  197 

conditions  requiring,  192 

dressing,  196 

elbow,  207 

elliptical  method,  199 

fingers,  205 

flap  method,  199 

foot,  210 

forearm,  206 

Gritti's,  213 

Guthrie's,  214 

Hancock's,  214 

hand,  205 

Hey's,  210 

hip-joint,  214 

instruments,  192 

interilioabdominal,  216 

intermediate,  203 

interscapulo-thoracic,  210 

knee-joint,  213 

Larrey's,  215 

Lee's,  212 

leg,  212 

Lisfranc's,  210 

medio-tarsal,  211 

metacarpal,  203 

methods,  197 

modified  circular  method,  199 

mortality,  203 

multiple,  200 

operative  procedure,  195 

oval  method,  199 

penis,  1050 

Pirogoff's,  211 

primary,  203 

secondary,  203 

Sedillot's,  212 

Senn's,  215 

shoulder-joint,  207 

Skey's,  210 

special,  205 

subastragalar,  211 

supracondylar,  213 

Syme's,  211 

Textor's,  211 

thigh,  213 

transcondylar,  213 

traumatic,  192 

wrist-joint,  206 
Anaplasty,  225 


Anastomosis,  intestinal,  832 
end-to-end,  833 
lateral,  834 
Murphy  button,  839 

nerve,  286 
Anatomical  tubercle,  76 
Anel's  ligation,  254 
Anemia,  splenic,  955 
Anesthesia,  148 

accidents,  151 

chloroform,  152 

ether,  149 

ethyl  chloride,  152 

general,  148 

administration,  153 
choice,  152 

in  head  operations,  153 

infiltration,  156 

in  intrathoracic  operations,  153 

intratracheal  insufflation,  154 

local,  155 

in  neck  operations,  153 

nerve  blocking,  157 

nitrous  oxide,  152 

primary,  150 

spinal,  157 

vein,  158 
Anesthetics,  148 
Aneurysm,  247 

by  anastomosis,  247 

Anel's  ligation,  254 

bone,  446 

Brasdor's  ligation,  255 

cirsoid,  247 

classification,  249 

dissecting,  249 

electrolysis,  256 

extirpation  of  sac,  256 

false,  248 

osteoid,  113,  446 

filipuncture,  256 

Hunter's  ligation,  254 

ligation,  254 

Matas's  operation,  257 

racemose,  247 

saccular,  249 

traumatic,  233,  247 

treatment,  253 

non-operative,  253 
operative,  253 

true,  248 

tubular,  249 

varicose,  235 

v(Mi()Us,  233 

\\'ar(lrop's  ligation,  255 

wiring,  256 
Aneurysmal  bruit,  252 

varix,  235 
Aneurysmoplasty,  258 
Angeioleucitis,  268 
Angeioma.    See  Heinangeioma 

of  breast,  713 
Angeiotripsy,  229 
Angina  Ludovici,  645 
Ankle  dislocation,  413 

tuberculosis,  500 


fXDKX 


HIT) 


Aiikli'-joiiit  amimtatioii,  "JII 
Ankylosis,  4(57 

ficatinciit,   KIT 

tul)('rculou.s,  4S7 
Aiioci-iissoriiitioii,  14S 
Aiilillcxioii  uteri,   lONd 
Alltel  liuracic      csopliaKO-jejtiiio-fiustro.s- 

loiny,  (')96 
Anteversion  uteri,  1086 
Anthrtix,  87 

treatment,  89 
Aiitihacteriul  sera,  45 
Antisepsis,  3(1,  131) 
Antiseptic  nietliods,  141 
Antiseptics,  31) 
Antitoxic  sera,  4.') 
Antitoxins,  23 
Antylkis,  operation  of,  2").') 
Anuria,  calculous,  981 
Anus,  carcinoma,  913 

false,  formation  of,  914 

fissure,  905 

surgery,  900 
Apoi)lexy,  576 
Appendicitis,  848 

acute,  851 

causes,  850 

chronic,  863 

complications,  857 

diagnosis,  852 

gangrenous,  861 

obliterans,  849 

operation,  854 

pathogenesis,  848 

peritonitis,  862 

simple  phlegmonous,  849 

symptoms,  851 

treatment,  854 

ulcerative,  849 
Appendicostomy,  896 
Appendicular  abscess,  858 

treatment,  860 
Appendix,  carcinoma,  864 

coprolith,  850 

cyst,  850 

empyema,  850 

fecal  conci'etion,  850 

foreign  bodies,  850 

intussusception,  864 

removal,  855 

stricture,  850 

surgery,  848 

tuberculosis,  864 
Arm,  amputation,  207 
Arrow-wounds,  170 
Arsenic  poisoning,  bones  in,  659 
Arterial  embolism,  242 

thrombosis,  241 

varix,  247 
Arteriectasis,  248 
Arteries,  ligation,  230 
methods,  231 
rules  for,  230 
Arteriosclerosis,  241 
Arteriovenous  wounfls,  235 
Arteritis,  241 


Arthreclomy,  486 
Arthritis,  4(V2 

acute,  of  infants,  4(>4 
rheumatic,  473 

atroi)liic,  452 

crypt  ogcnous,  473 

deformans,  452 

gonococcic,  471 

hypertrophic,  45(i 

metastatic,  473 

nodosa,  452 

pneumococcic,  471 

rheumatoid,  452 

senil(>,  456 

subpycmic,  473 

sy|)hilitic,  503 

tuberculous,  476 

operation  in,  486 

tyi)hoid,  472 

villous,  462 
Arthrodesis,  528 
Arthrolysis,  468 
Arthroplastj',  471 
Ascites,  940 
Asepsis,  36,  139 
Aseptic  fever,  70 

methods,  141 
Ashhurst's  amputation,  212 

excision  of  knee,  469 
Aspiration,  147 
Astragalectomy,  521 
Astragalus,  dislocation,  414 

fracture,  383 
Auditory  canal,  furuncle,  628 
Auricle,  prominence  of,  629 

supernumerary,  629 
Autotransfusion,  175 
Axillary  abscess,  729 

infusion,  144 
Azotorrhea,  947 


B 

Bacillary  dj'sentery^  895 
Bacteria  in  inflammation,  18 
pathogenic,  18 
pyogenic,  28 
saprophytic,  19 
toxins,  19 
Bacteriemia,  70 
Bacteriolysins,  23 
Bacteriuria,  964 
Balanitis,  1048 
Balano-posthitis,  1048 
Bandage,  figure-of-eight,  135 
many-tailed,  135 
plaster  of  Paris,  137 
recurrent,  135 
of  Scultetus,  135 
spiral,  135 

reversed,  135 
T-,   135 
varieties,  135 
Bandaging,  133 
Banti's  disease,  955 


1110 


INDEX 


Bartholin's  gland,  cyst  of,  1072 
Bartholinitis,  1071 
Barton's  fracture,  355 
Basedow's  disease,  688 
Bassini's  operation,  787 
Bayonet  wounds,  170 
Bazin's  disease,  264 
Beck's  bismuth  paste,  484 

operation,  1044 
Bod-sore,  62 
Bezold's  abscess,  631 
Bier's  hyperemia,  40 
Bile-ducts,  carcinoma  of,  942 

infections,  919 

operations,  928 

surgery,  919 
Biliary  calculus,  formation  of,  919 

colic,  924 

fistula,  post-operative,  928 

sand,  922 
Billroth's  amputation,  216 

gastrectomy,  881 

powder,  219 
Birth  injuries,  1081 
"Birth-mark,"  244 
Bismuth  paste,  484 
Bistoury,  49 
Bites,  170 
Bladder,  calculus  in,  966 

carcinoma,  966 

diverticula,  965 

exstrophy,  962 

foreign  bodies,  971 

injuries,  971 

irrigation,  964 

papilloma,  966 

post-prostatic  pouch,  1031 

rupture,  971 

surgerj-,  958 

tuberculosis,  965 

tumors,  966 
Blank  cartridge  wounds,  186 
Blastoma,  104 
Blastomatoid  growths,  107 
Blastomycosis,  86 
Blood-vascular  system,  diseases,  237 

surgery,  227 
Bloodvessels,  gunshot  wounds,  186 

subcutaneous  injuries,  233 

suture  of,  234 

wounds,  233 
Boas's  area,  924 
Boil,  261 
Bone  abscess,  437 

aneurysm,  446 

atrophj',  416 

carcinoma,  450 

caries,  431 

congenital  absence,  504 

cysts,  445 

diseases,  416 

felon,  280 

fibromas,  445 

gunshot  wounds,  186 

infection,  425 

lacunar  resorption,  416 


I  Bone  necrosis,  431 

osteomyelitis,  426 
Paget's  disease,  423 
sarcoma,  446 
syphilis,  440 
transplantation,  504 
tuberculosis,  437 
tumors,  443 
wax,  435 
Bottini  operation,  1036 
"Bottle  operation,"  1060 
Bougie  a  boule,  1015 
Bougies,  1015 

filiform,  1015 
Braces,  611 
Bradford  frame,  482 
Brain  abscess,  579 

treatment,  581 
compression,  571 
concussion,  569 
contusion,  569 
cysts,  582 
endothelioma,  581 
sarcoma,  582 
surgical  affections,  567 
syphiloma,  581 
tuberculoma,  581 
tumor,  581 

decompressive    operat ion, 

589 
treatment,  585 
Branchial  cysts,  682 
Branchiogenic  carcinoma,  683 
Brasdor's  ligation,  255 
Breast,  ablation  of,  721 
abscess,  701 
adenoma,  713 
adeno-sarcoma,  712 
amputation,  710 
angeioma,  713 
caked,  700 
cancer  cyst,  720 
carcinoma,  714 

cauterization,  726 
extension,  720 
inoperable,  725 
medullar}',  719 
oophorectomy,  726 
operation,  radical,  721 

end-results,  725 
recurrence,  725 
scirrhous,  715 
simplex,  719 
congenital  anomalies,  699 
cystudcnoma,  712 
cj-stadenomatosis,  707 
cystic  disease,  707 
cystosarcoma  phyllodes,  712 
enchondroma,  713 
endothelioma,  713 
fibro-adenoma,  711 
fibro-adenomatosis,  706 
fibrocystadenoma,  712 
gumma,  704 
hydatid  disease,  712 
hypertrophy,  idiopathic,  706 


INDEX 


1117 


lircast,  hypcrtniijliy,  senile  ii.iKMicliyiiiii- 
luiis,  707 

involution,  707 

irritable  t Minor,  702 

lil)onia,  71.'5 

myxoma,  71 1 

neuralfiia,  702 

l)a|)illary  cystadenoma,  712 

plastic  resecition,  711 

sarcoma,  713 

scirrhus,  715 

sero-cystic  sarcoma,  712 

surgery,  699 

syphilis,  704 

tuberculosis,  704 

tumors,  705 
benign,  710 
malignant,  713 
Brisemeiit,  force,  468 
Broad  ligament  cyst,  1099 
Brodie's  abscess,  437 
Bronchiectasis,  749 
Bronchoscopy,  666 
Brvant's  line,  364 
Bubo,  269 

chancroidal,  1006 

parotid,  624 

syphilitic,  992 
Bubon  d'emblee,  269 
Bubonocele,  779 
Budih's  sign,  701 
Bulbar  symptoms,  572 
Bullet  wounds,  183 
Bunion,  259 
Burns,  217 

duodenal  ulceration,  218 

electric,  222 

treatment,  219 

wounds,  266 

a:-ray,  222 
Bursitis,  267 


Cachexia  in  malignant  growths,  103 

thyTeopriva,  688 
Caked  breast,  700 
Calcaneiun,  fracture,  383 
Calculous  anuria,  981 
Calculus,  biliary,  formation  of,  919 
varieties,  922 

lacteal,  704 

pancreatic,  949 

preputial,  1048 

renal,  977 

salivary,  627 

ureteral,  981 

urinarj',  formation  of,  977 

vesical,  966 
Callositas,  259 
Callous  ulcer,  55 
Callus,  304 

Cammidge  reaction,  948 
Cancer  cyst  of  breast,  720 


Caiicrum  oris,  63 
Capillar}'  nevi,  244 
Caput  obstipum,  537 

succedaneum,  551 
Carbolic  acid  gangrene,  60 
Carbuncle,  2()1 

of  lip,  641 
Carcinoma,  1 19,  123 

anus,  913 

ajjpendix,  864 

l)asal-celled,  123 

bile-ducts,  942 

bladder,  966 

bone,  450 

breast,  714 

cauterization,  726 
extension,  720 
inoperable,  725 
operation,  radical,  721 

end-results,  725 
recurrence,  725 

cecum,  895 

cervix,  1109 

colunmar-celled,  125 

cylindrical-celled,  125 

encephaloid,  126 

epiblastic,  119 

esophagus,  698 

gall-bladder,  942 

glandular,  125 

hypoblastic,  119 

jaw,  660 

kidney,  983 

larymx,  668 

liver,  941 

lymph  nodes,  273 

medullary,  125 

pancreas,  950 

penis,  1049 

permeation,  120 

prostate,  1042 

rectum,  913 

scirrhous,  125 

simplex,  126 

solid-celled,  125 

squamous-celled,  121 

stomach,  873 

thyroid,  692 

tongue,  649 

tonsil,  664 

treatment,  127 

uterus,  1109 

vulva,  1112 
Cardiolysis,  237 
Caries  of  ribs,  731 

sicca,  477 

of  skull,  429 
Carotid  gland,  tumors  of,  680 
Carpus,  dislocation,  404 

fracture,  359 
Castration,  1056 
Catarrhal  jaundice,  921 
Catheter,  double-elbowed,  1034 

introduction,  959 

Mercier,  1034 
Catheterism,  1034 


1118 


IXDEX 


Catheters,  958 
Cauterization,  142 
Cavernous  anfjeiomas,  245 

sinus  thrombosis,  577 
Cecal  hernia,  785 
Cecostomj',  896 
Cecum,  carcinoma,  895 

mobile,  898 
Cellulitis,  66 

pelvic,  1094 
Cephalhematoma,  551 
Cephalocele,  553 
Cerebral  palsies,  530 
Cerebritis,  579 
Cervical  ribs,  539 
Cervix,  carcinoma,  1109 

laceration,  1081 

stenosis,  1070 
Chancre,  83,  989 

Hunterian,  83 

mixed,  991 

superficial  erosion,  83 

of  tongue,  649 
Chancroid,  1005 

treatment,  1007 
Chancroidal  bubo,  1006 

treatment,  1008 
Charbon,  87 
Charcot's  intermittent  fever,  926 

joint,  460 
Chauffeur's  fracture,  355 
Cheeks,  epithelioma,  624 

keratosis  senilis,  622 

lupus,  624 

plastic  operations,  623 

rodent  ulcer,  624 

seborrheic  patch,  622 

surgerv,  622 
Cheloid,  109 
Chemotaxis,  negative,  21 

positive,  21 
Chest  wall,  injuries,  726 

malformations,  726 

rachitic  deformities,  726 

surgerv,  699 
Chilblain,  222 
Chloroform  anesthesia,  152 
Chloroma,  114 
Cholangeitis,  921 
Cholecystectomy,  931 
Cholecystendysis,  930 
Cholecystenterostomj',  934 
Cholecystoduodenostomy,  934 
Cholecysto-gastrostomv,  934 
Cholecystitis,  919 

calculous,  925 

chronic,  920 

treatment,  921 
Choledocho-enterostomy,  928 
Choledochostomy,  932 
Choledochotomj',  932 

retroduodenal,  933 

transduodenal,  934 
Cholelithiasis,  922 

Murphy's  test,  924 

simple,  923 


Cholelithiasis,  treatment,  926 
Cholemia,  926 
Cholesteatoma,  129 
Cholesterin,  gall-bladder,  922 
Chondrectomy,  748 
Chondroma,  ilO 
Chondrosarcoma,  116 
Chopart's  amputation,  211 
Chordoma,  114 
Chorio-epithelioma,  106,  1111 
Chromoureteroscopj',  961 
Chvle  duct,  wounds  of,  268 
Chylothorax,  268,  738 
Chylous  ascites,  268 
Cicatrization,  30,  53 
Cigarette  drain,  52 
Cinematoplastic  amputation,  202 
Circumcision,  1046 
Cirrhosis,  liver,  940 

of  stomach,  872 
Cirsoid  aneurvsm,  247 
"Clacking  jaw,"  392 
Clavicle,  dislocation,  392 

fracture,  326 
Clavus,  259 
Cleft  palate,  634,  638 
operation,  638 

scrotum,  1043 
Cloaca^,  426 
Cloquet's  hernia,  794 
Club  foot,  515 

hands,  515 
Cocain  anesthesia,  155 
Coccj'godynia,  325 
Coccyx,  fracture,  325 
Cock's  operation,  1025 
Coin-catcher,  694 
Cold  abscess,  79 

effects  of,  221 
Coley's  fluid,  117 
Colic,  renal,  979 
Colitis,  895 
Collapse,  172 
CoUes's  fracture,  351 

law,  998 
Colon,  surger.y  of,  895 
Colostomv,  915 
Colpocele,  1082 

anterior,  1088 
Colpo-perineorrhaphy,  1083 
Colporrhaphy,  posterior,  1083 
Common  duct,  obstruction,  928 

stone  in,  925 
Compression  of  brain,  571 

treatment,  574 
Concussion  of  brain,  569 

of  spinal  cord,  594 
Condylomata  lata,  995 
Congenital  absence  of  bone,  504 

deformities,  504 

megacolon,  900 

talipes,  515 
Congestion,  20 
Constipation,  899 
Contracture,  palmar  fascia,  542 

Volkmann's,  540 


IXDI-X 


111!) 


Contniftun's  of  imisclcs,  270 
Contused  wounds,  1()7 
Contusion,  151) 

ahdoniiniil  wall,  HW 
l)rain,  ")t')9 
joints,  385 
nerves,  2S2 
scalp,  o")! 
Cooper's  hernia,  7!)4 
Corn,  259 

Cornu  eutanoum,  2(i() 
Corona  veneris,  !)i)5 
Corpus  luteuni  eyst,  H)i>7 
Corset  liver,  985 
Costo-t ransversectoniy,  0 1 4 
Countw-irritation,  142 
Courvoisier's  law,  926 
Coxa  valga,  540 

vara,  543 
Coxalgia,  4S8 

Cranial  defects,  repair,  567 
Craniocerebral  topography,  567 
Craniotomy,  osteoplastic,  5S6 
Cricothyrotoniy,  670 
Critical  discharges,  31 
Crural  hernia,  793 
Crushed  limbs,  treatment,  204 
Crutch-palsy,  282 
Cryoscopy,  902 
Cryptogenous  arthritis,  473 
Cryptorchidism,  1050 
Cubitus  valgus,  346,  540 

varus,  346,  540 
Cuneiform  tarsectomy,  521 
Cushing's  decompressive  operation, 

suture,  831 
Cut-throat,  673 
C}'lindroma,  128 
Cyst  or  cysts,  129 

appendix,  850 

Bartholin's  gland,  1072 

bone,  445 

brain,  582 

branchial,  682 

broad  ligament,  1099 

corpus  luteum,  1097 

dentigerous,  112,  661 

dermoid,  of  ovary,  1101 
of  scalp,  553 

extravasation,  129 

Graafian  follicle,  1097 

hydatid,  131 

kidney,  984 

lip,  640 

liver,  echinococcus,  938 

mesenteric,  895 

omental,  895 

ovary,  1097 

dermoid,  1101 

pancreas,  952 

parasitic,  131 

parovarian,  1099 

pilo-nidal,  130,  266 

retention,  129  • 

sebaceous,  265 
of  scalp,  553 


590 


Cyst  or  cj'sts,  sequestration,   130 

spleen,  955 

thyro-glossal,  6S1 

tul)o-()varian,  1098 

urachal,  963 
Clystadeno-carcinoma,  1 25 
Cyst  adenoma,  119 

breast,  707,  712 

ovary,  1098 

])apilliferum,  119 
Cystadenomatosis  of  breast,  707 
Cystic  duct,  stone  in,  925 
Cystitis,  903 
Cystocelc,  1082,  1088 

operation,  1088 
Cystoscope,  900 
Cystotomy,  suprapubic,  970 
Czerny's  suture,  829 

Winkelschnitt,  928 


Dactylitis,  syphilitic,  441 

tuberculous,  439 
Dance's  sign,  886 
"Dangle-foot,"  528 
Deaver's  incision,  820 
Deciduoma  malignum,  106,  1111 
Decompression,  574 
Decompressive  operation,  589 
Decortication  of  lung,  745 
Decubitus,  62 
Deformities,  congenital,  504 

of  head,  537 

of  neck,  537 

paralytic,  521 
Delirium  cordis,  690 

traumatic,  173 

tremens,  174 
Demarquay's  operation,  1018 
Dentigerous  cyst,  112,  661 
Dermatitis,  x-ray,  222 
Desmoids,  277 
Determination  of  l)lood,  20 
Diacondylar  fractures,  341 
Diapedesis,  20 
Diaphragm,  eventration,  751 

gunshot  wounds,  750 

hernia,  751 

rupture,  750 

stab  wounds,  749 

surgery,  749 
Dietls's  crises,  972 
Digital  abscess,  279 
Dilatation  of  esophagus,  697 

of  stomach,  acute,  869 
secondary,  870 
Discission  of  pleura,  746 
Disinfection,  iodin,  141 
Dislocated  kidney,  973 

spleen,  955 
Dislocation  of  acromio-clavicular  joint, 
393 

ankle,  413 


1120 


IXDEX 


Dislocation  of  astragalus,  414 

carpal  bones,  404 

clavicle,  392 

elbow,  399 

fingers,  40.5 

hip,  405 

congenital,  507 

humerus,  394 

knee,  412 

congenital,  515 

mandible,  391 

mediotarsal  joint,  415 

metacarpus,  404 

metatarsus,  415 

nerves,  283 

patella,  279 

phalanges,  404 

radiocarpal  joint,  403 

radius,  head  of,  402 

sacro-iliac  joints,  405 

scapula,  394 

shoulder,  394 

congenital,  513 

spine,  594 

sternoclavicular  joint,  392 

tarsus,  414 

tendons,  278 

tibiotarsal  joint,  413 

vertebrae,  594 

WTist,  403 
Dislocations,  387 

causes,  388 

complicated,  391 

compound,  390 

congenital,  507 

consecutive,  388 

old,  391 

pathological,  388 

primitive,  388 

recurrent,  391 

reduction,  390 

special,  391 

spontaneous,  388 

subastragalar,  415 

traumatic,  388 

treatment,  390 
Dissecting  aneurj'sm,  249 
Diverticulum  of  bladder,  965 

of  esophagus,  697 
Diverticulitis,  sigmoid,  897 
Drainage  tube,  51 
Dressing  forceps,  49 

wounds,  166 
Dudlej^'s  operation,  1070 
Duodenum,  ulcer,  864 
in  burns,  218 
chronic,  865 
hemorrhage,  868 
perforation,  867 
treatment,  866 
Dupuytren's  contracture,  542 

suture,  831 
Dysentery,  amebic,  895 

bacillary,  895 
Dystrophies  of  bone,  416 

of  joints,  451 


E 


Ear,  foreign  bodies  in,  628 

surger.y  of,  628 
Ear-ache,  630 
Ecchondroma,  110 
Ecchymosis,  159 
Echinococcus  cyst  of  liver,  938 
Eck's  fistula,  941 
Ectopic  gestation,  1090 
Edema  of  glottis,  668 
Edematous  ulcer,  54 
Elbow,  amputation,  207 

dislocation,  399 

excision,  470 

tuberculosis,  501' 
Electric  current  injuries,  217 
Elephantiasis  Arabum,  271 

of  scrotum,  1062 
Embolism,  73,  237 

arterial,  241 

mesenteric,  890 

post-operative,  178 

pulmonary,  178,  241 

retrograde,  73 
Embolus,  73 
Embr}'oma,  106 
Empyema  of  appendix,  850 

articuli,  462 

gall-bladder,  920 

necessitatis,  740 

thoracis,  739 

bilateral,  744 
Emphysema,  pulmonary,  748 

surgical,  728 
Emphysematous  gangrene,  65 
Encephalitis,  579 
Encephalocele,  553 
Encephalocystocele,  553 
Enchondroma,  110 

of  breast,  713 
Endo-aneurysmorrhaph}',  257 
Endocervicitis,  1073 
Endometritis,  1073 

putrid,  1093 

septic,  1094 
Endosteoma,  111 
Endostosis,  112 
Endothelioma,  127 

of  brain,  581 

of  breast,  713 
Endotoxins,  bacterial,  19 
End-to-end  anastomosis,  833 
Enostosis,  112 
Enterocele,  755 
Entero-epiplocele,  755 
Enterorrhaphy,  circular,  832 
Epicondylitis,  342 

Epidemic  cerebrospinal  meningitis,  57J 
Epididymitis,  1052 
Epididymo-orchitis,  1052 
Epididymo-vasostomy,  1053 
Epigastric  hernia,  771 
Epignathus,  106 
Epilepsy,  focal,  590 

Jacksonian,  590 


LXhKX 


l']|)i|)l()C('l(',  7.").") 
Epiphyseal  .separation,  '-".Id 
I'lpipliysitis,  acute,   \'M\ 
I'lpispailias,  101") 
I'lpistaxis,  (il!) 
lOpillielioiiia,   121 

of  cliecks,  ()24 

deep-seated,   121 

of  lip,  on 

pai)illarv,  12;i 

pearly  Ixxlies,   122 

of  scalp,  rt')'A 

superficial,  123 
I'lpitrochlea,  fracture,  344 
KlJiilis,  ()()() 
Mrasioii  of  joiut.s,  4S6 
I'j-etliistic  shock,  173 
Erysipelas,  67 

phlegmonous,  09 

treat lueut,  (i!) 
iM-ytheina  induratuiu,  2()4 

nodosum,  2G4 
Ksmarch  anemia,  433 
Esmarch's  elastic  band,  194 
Esophagotoniy,  external,  ()94 

internal,  695 
Esophagus,  carcinoma,  098 

dilatation,  697 

diverticulum,  697 

foreign  bodies,  693 

imperforation,  697 

stricture,  695 

surgery,  693 
Est  lander's  operation,  746 
Ether  anesthesia,  149 
Ethmoidal  disease,  655 
Ethyl  chloride  anesthesia,  152 
Eucain  anesthesia,  155 
Eventration  of  diaphragm,  751 
Evidement,  436 
Excision  of  elbow,  470 

of  hip,  497 

of  inferior  maxilla,  662 

of  joints  for  ankylosis,  469 

of  knee,  469 

of  shoulder,  470 

of  superior  maxilla,  662 

of  wrist,  470 
Excoriation,  159 
Exophthalmic  goitre,  688 
Exostoses,  cartilaginous,  443 

fibrous,  444 

subungual,  444 
Exostosis,  112 

bursata,  445 
Exploring  needle,  4i) 
Exstrophy  of  bladder,  962 
Extradural  hemorrhage,  574 
Extra-uterine  pregnancy,  1090 


Facial  hemiatrophy,  660 
False  anus,  831,  893,  914 
Farcy,  89 
71 


l''at-eiul)olism,   178 

necrosis,  944 
Fecal  fistula,  893 

impaction,  88!) 
Felon,  280 

Female  genitals,  surgery  of,  1064 
Femoral  hernia,  793 

treatment,  795 
Femur,  fracture,  362 

shaft  of,  fracture,  368 
Fever,  70 

asei)t  ic,  70 

surgical,  71 
Fibrin,  24 
Fibro-adenoma,  119 

of  breast,  711 
Fibro-adenomatosis  of  breast,  706 
Fibroid,  114 

recurrent,  116 

of  uterus,  1102 

treatment,  1106 
Fibroma,  108 

bone,  445 

molluscum,  108 

neck,  684 
Fibromatosis  nervorum,  114 
Fibromyoma  of  uterus,  1102 
Fibromyxoma,  109 
Fibrosarcoma,  109,  116 
Fibula,  fracture  of,  379 
Filaria  sanguinis  hominis,  271 
Filariasis,  271 
Filiform  bougies,  1015 
Filipuncture  in  aneurysm,  256 
P'ingers,  amputation,  205 

congenital  contraction,  506 

supernumerary,  505 

webbed,  506 
Finney's  pyloroplasty,  879 
Fissure  of  anus,  905 

of  nipple,  700 

of  Rolando,  568 
Fistula,  48,  52 

in  ano,  904 

biliary,  921 

postoperative,  928 

blind,  52 

branchial,  682 

Eck's,  941 

gastro-colic,  891 

genital,  1089 

pancreatic,  946 

pilo-nidal,  266 

pleural,  744 

recto-genital,  913 

recto-urethral,  913 

recto-urinary,  913 

recto-uterine,  913,  1089 

recto-vaginal,  913 

salivary,  626 

suprapubic,  103(5 

thj-ro-glossal,  681 

treatment,  52 

umbilical,  891 

urachal,  963 

uretero-cervical,  1089 


1122 


INDEX 


Fistula,  urinarv,  1027 

vesico-utcrinc,  913,  10S9 

vesico-vaginal,  913,  1089 
F"ixed  dressings,  137 
Flat-foot,  547 
Floating  kidney,  973 
Fluxion  of  blood,  20 
Focal  epilepsy,  590 

symptoms,  572 
Foot,  amputations,  210 

fracture,  3S2 
Forearm,  amputations,  206 

fractures,  355 
Foreign  bodies  in  air  pas.sages,  665 
in  appendix,  850 
in  bladder,  971 
in  ear,  628 
in  esophagus,  693 
in  nose,  620 
in  soft  parts,  169 
Fowler's  position,  811 
Fracture,  acetabulum,  325 

astragalus.  3S3 

Barton's,  355 

calcaneum,  383 

carpus,  359 

chauffeur's,  355 

clavicle,  326 

coccyx,  325 

Colles',  351 

elbow,  338 

face  bones,  320 

femur,  362 
shaft,  368 

fibula,  379 

forearm,  355 

hip,  362 

humerus,  331 
shaft.  336 

larvnx,  667 

leg,  376 

malar  bone,  320 

mandible,  321 

maxilla,  321 

metacarpus.  361 

metatarsus,  384 

by  muscular  action,  297 

nasal  bones,  320 

olecranon,  348 

patella,  372 

jAalanges,  362,  384 

r  el  vie  bones,  323 

Pott's,  380 

radius,  350 

ribs,  323 

scapula,  330 

skull,  557 

spine.  594 

sternum.  322 

supracondylar,  of  humerus,  339 

tarsus,  382 

tibia,  376 

trochanter,  368 

uhia.  348 

veitebrap,  594 

zygoma,  320 


Fractures,  294 

after-care,  309 

badly  united,  treatment,  315 

callus,  304 

causes,  297 

classification,  294 

comminuted,  294 

complete,  294 

complicated,  295 
treatment,  312 

compoimd,  294 

treatment,  312 

delayed  union,  306 

depressed,  296 

diagnosis,  301 

double,  294 

green-stick,  294 

gunshot,  186 

impacted,  296 

incomplete,  294 

mechanism,  297 

multiple,  295 

pathological,  298 

process  of  union,  303 

ring,  559 

simple,  294 

treatment,  307 

operative,  310 

skiagraphy,  302 

special,  319 

spontaneous,  298 

sprain,  298 

symptoms,  298 

treatment.  306 

ununited,  306,  316 
treatment,  317 
Fragilitas  ossium,  416 
Frazier-Spiller  operation,  292 
Friar's  balsam,  638 
Frost-bite,  221 
Fungus  cerebri,  590 
Fininel  breast,  726 
Furuncle,  261 

auditory  canal,  628 


Galactocele,  703 
Gall-bladder,  carcinoma,  942 

cholesterin,  922 

em])vema,  920 

hydrops,  920 

infections,  919 

operations,  928 

perforation,  921 

strawberry,  922 

surgery,  919 
(Jail-stones,  formation  of.  919 

in  coinnion  duct,  925 

in  cystic  duct.  925 

in  hei)atic  duct,  926 

migrated,  925 

varieties,  922 
Gait's  trephine,  563 
Ganglion,  281 


IXDKX 


1123 


(Janj^lion,  fr;iss(>rian,   oxtir|)ati()n  ol",  1291 
( lanttrciic,  oS 

arterial  occlusion,  trcalnicnt,  (i'J 

causes,  f)!* 

(•arl)()lic  acid,  ()() 

(liahet  ic,  treat  itieiit,  (il 

dry,  <)() 

eiii])liyseiiiatoUS,  (').") 

i'oiidroyaiite,  ().") 

liospit.al,  iV.i 

line  of  demarcation,  (id 
oi  separation,  (iO 

of  lung,  748 

moist,  ()() 

of  pancreas,  i)4() 

.senile,  59 

trout ment,  01 

spreading,  65 

symmetrical,  64 

symptoms,  60 

traumatic,  65 

treatment,  61 

varieties,  60 
Caiigrenous  stomatitis,  63 
Gartncu-'s  duct,  1099 
Gasserian  ganglion,  extirpation  of,  291 
Gastrectomy,  881 

Billroth's,  881 

Hartmann's  line,  874 

partial,  881 

subtotal,  884 

total,  884 
Gastric  ulcer,  864 
Gastro-anastomosis,  872 
(Jastro-colic  fistula,  891 
Gastrogastrostomy,  872 
Gastro-intestinal  tract,  rupture  of,  842 
Gastrojejunostomy,  879 
Gastro'plasty,  87l" 
( lastrostomy,  877 
Gastrotomy,  876 
(Genital  fistula,  1089 
Genitalia,  female,  examination,  1065 
(Jenitals,  female,  surgery  of,  1064 

male,  surgery  of,  1043 
Gcrsuni's  operation,  910 
Gestation,  ectopic,  1090 
Glanders,  89 
Gleet,  1011 
Glioma,  114 

brain,  581 
(iliosarcoma,  116 
Glossitis,  647 
Glottis,  edema  of,  668 
CJluteal  abscess,  607 
Goitre,  684 

colloid,  685 
cystic,  ()86 
diffuse,  685 
exo])lithalmic,  (588 
nodular,  ()86 
operation,  ()87 
I)arenchymatous,  685 
treatment,  687 
Gonococcic  joint  infection,  471 
urethritis,  1010 


Gonorrheji,  1009 
female,  1070 
treatment,   101  I 

abortive,   1012 

autogenous  vaccines,   101  I 

prophylactic,  101 1 
Gia.'iliaii  follicle  cyst,  1097 
( Iiamdation  tissue,  26,  30 

tuberculous,  79 
( iraiiulations,  30,  53 
( ii'amdouia,  infectious,  19,  7() 
(ii'aves's  disease,  688 
(iritti's  amputation,  213 
Gumma  of  breast,  704 
of  testicle,  1057 
of  tongue,  649 
Ciummas,  84,  997 
Gunshot  wounds,  180 

of  alxlomen,  191,  844 

of  iilood vessels,  186 

of  bones,  18(i 

of  diaphragm,  750 

of  head,  188 

of  intestine,  845 

of  joints,  186 

of  liver,  847 

of  lungs,  189 

of  nerves,  186 

of  pancreas,  847 

of  spine,  189 

of  spleen,  847 

of  stomach,  846 

of  thorax,  189 
Guthrie's  amputation,  214 
Gypsum,  137 


Hallux  valgus,  549 
Halsted's  suture,  831 
Hammer  toe,  549 
Hancock's  amputation  of,  211 
Hand,  amjjutation,  205 
Hare-lip,  634 

double,  637 

single,  635 
Harrison's  groove,  726 
Hartmann's  line  for  gastrectomy,  874 
Head  deformities,  553 

gunshot  injuries,  188 

oi)erations,  anesthetic,  153 

surgery  of,  551 
Heart,  foreign  bodies  in,  237 

injuries,  236 

massage,  237 

ruj^ture,  236 

wounds,  236 
Heat,  effects  of,  217 

prostration,  post-operative,  179 
Heberden's  nodes,  456 
Hecti(!  fever,  75 
Heliotherapy,  484 
Hemangeio-endothelioma,  1 28 
Hemangeioma,  244 
Hemarthrosis,  387 


1124 


INDEX 


Hematocele,  1061 
Heinatocolpos,  1069 
Hematoma,  160,  233 

auris,  629 
Hematometra,  1069 
Hematomyelia,  594 
Hemiatrophy,  facial,  660 
Hemilaryngectomy,  672 
Hemophilia,  227 
Hemorrhage,  227 
apparent,  227 
arterial,  227 
concealed,  227 
(ionstitiitional  signs,  227 
extradural,  574 
internal,  227 

intestinal,  in  typhoid,  893 
intracerebral,  576 
intradural,  575 
middle  meningeal,  575 
operative,  176 
primary,  177 
reactionary,  177 
secondary,  177,  232 
treatment,  232 
subcranial,  574 
subcutaneous,  227 
treatment,  228 

acupressure,  229 
cold,  229 
forcipressure,  229 
heat,  229 
ligation,  229 
position,  228 
l)ressure,  228 
styptics,  229 
torsion,  229 
venous,  227 
Hemorrhagic  pancreatitis,  914 

peritonitis,  805 
Hemorrhoids,  906 

treatment,  907 
Hemothorax,  737 
Hepatic  duct,  stone  in,  926 
Hepatico-enterostomy,  928 
Hepaticus  drainage,  933 
Hepatitis,  suppurative,  936 
Hepatoptosis,  935 
Hepatotomy,  937 
Hermaphrodism,  1045 
Herpes  progenitalis,  1048 
Hernia,  753 

causes,  754 
cecal,  785 
cerebri,  590 
classification,  770 
of  Cloquet,  794 
of  Cooper,  794 
crural,  793 
diai:)hragmatic,  751 
cnterocele,  755 
entero-epiplocele,  755 
epigastric,  771 
epiplocele,  755 
femoral,  793 

operation,  795 


Hernia,  femoral,  rare  forms,  794 
strangulation,  799 
treatment,  795 
of  Hesselbach,  794 
incarcerated,  761 

treatment,  761 
incisional,  772 
inHamcd,  760 
inguinal,  779 

complete,  783 
direct,  792 

treatment,  793 
incomplete,  783 
nomenclature,  779 
oblique,  780 

operation,  787 
treatment,  785 
properitoneal,  784 
strangulation,  784 
truss,  786 
inguino-crural,  785 
irreducible,  759 

treatment,  760 
ischiatic,  801 
labial,  779 
Laugier's,  794 
Littre's,  755 
lumbar,  779 
lung,  736 
muscle,  274 
nomenclature,  754 
obstructed,  760 
obturator,  799 
Partridge's,  794 
pectineal,  794 
perineal,  800 
preperitoneal  fat,  771 
pudendal,  800 
recurrence,  785 
reducible,  756 

treatment,  757 
retrovascularis,  794 
Richter's,  755 
sac,  754 

contents,  755 
sigmoid,  785 
sliding,  785 
special,  770 
strangulated,  761 
operation,  766 
taxis,  766 
treatment,  765 
suj)ravesical,  792 
taxis,  766 
of  Tessier,  794 
truss,  758 
umbilical,  774 
adult,  776 
congenital,  774 
infantile,  774 
strangulated,  778 
vaginal,  800 
ventral,  772 
Hesselbach's  hernia,  794 
Hey's  amputation,  310 
Hilton's  method  of  opening  abscesses,  675 


INDEX 


112.5 


Hip,  central  dislocation,  32.') 

dislocation,  40.') 

conficnital,  .")n7 

excision,  4*J7 

fract>in',  MVl 

tnberculosis,  4S.S 
Hip-joint  amputation,  214 
Hirschsprung's  disease,  000 
Hodgkin's  di.sea.se,  114,  271 
Hollow  foot,  .51.5 
Horn,  260 

Horse-shoe  kidney,  072 
Horslej's  wax,  .5SS 
Hospital  gangrene,  (io 
Hour-glass  stomach,  871 
"  Hou.semaid's  knee,"  267 
Hudson's  trephine,  56.3 
Humerus,  dislocation,  394 

fracture,  331 

shaft,  fracture,  336 
Hunterian  chancre,  83 
Hunters  ligation,  254 
Hutchin.son's  teeth,  1000 
Hydatid  cyst  of  liver,  938 

di.sea.se  of  breast,  712 

of  Morgagni,  1099 
Hydrarthrosis,  intermittent,  466 
Hydrencejihalocele,  553 
Hydrocele,  105S 

acquired,  1059 

acute,  1053 

of  canal  of  Xuck,  1061 

congenital,  1058 

of  the  cord,  1060 

encysted,  of  cord,  1061 
of  tunica,  1061 

funicular,  1060 

operation,  1060 

treatment,  1060 

vaginal,  1059 
Hydrocephalus,  554 

acquired,  554 

congenital,  555 
Hydronephrosis,  976 
Hj'clrophobia,  96 

furious,  97 

jjaralj-tic,  97 

Pasteur  treatment,  99 
Hvdrops  articuli,  462 

of  gall-bladder,  920 
Hydrorachis,  592 
Hytlrosalpinx,  1077 
Hydrothorax,  729 
Hj-groma,  683 
Hylomas,  106 

Hyperemesis  lactantium,  869 
Hj'peremia,  active,  20 

passive,  20 
Bier's,  40 
Hypernephroma,  127,  983 
Hjperostosis,  112 
Hypertrophy  of  bone,  424 

of  prostate,  1029 
Hyperthyroidism,  688 

treatment,  690 
Hypodermic  injections,  143 


Hyj)odermoclysis,  144 
Hjpoleukocytosis,  31 
Hypospadias,  1043 
Hypothyroidism,  684,  688 
Hysterectomy,  abdominal,  1106 

vaginal,  1108 
Hysteropexy,  1086 


Ichthyosis  of  tongue,  647 
Idiopathic  fragilitas  o.ssium,  416 

sijlenomegal}',  956 
Ileus,  884 
Iliac  abscess,  607 
Imperforate  anus,  902 

esophagus,  697 

hymen,  106!) 

rectum,  902 

vulva,  1069 
Incarcerated  hernia,  761 
Incised  wounds,  160 
Incision,  abdominal,  818 
closure,  821 

Czerny's,  928 

Davis's,  821,  854 

Deayer's,  821 

gridiron,  829 

Kehr's,  928 

kidnej',  985 

McBurnev's,  820 

:Mayo  Robson's,  820,  928 

muscle-splitting,  820 

Sprengel's,  928 

transverse,  821,  854,  928 
Incisional  hernia,  772 
Indian  rhinoplasty,  621 
Indigo-carmine  test,  961 
Infantile  paralj'sis,  521 
Infants'  arthritis,  464 
Infectious  granulomas,  19,  76 
Infiltration  anesthesia,  156 
Inflammation,  17 

alexins,  23 

antitoxins,  23 

bacteriolysins,  23 

causes,  18 

bacteria,  18 
exciting,  18 
predisposing,  18 
toxins,  19 

cellular  infiltrate,  22 

chronic,  35 

cure,  37 

diapedesis,  20 

diseases  resulting  from,  47 

extension,  27 

fever,  70 

fibrin,  24 

fibroblasts,  22 

leukocj-tes,  22 

lymphization,  23 

IjTnphocytes,  22 

Ij-mphogenesis,  23 

margination,  20 


U26 


INDEX 


Inflammation,  mifrratiori,  20 
modified  forms,  70 
nervous  system,  27 
l)atliology,  19 

summary,  29 
phlegmonous,  2(') 
pyrexia,  70 
regeneration,  30 
repair,  29 
resolution,  23 
resulting  affections,  70 
subacute,  35 
symptoms,  31 

heat,  33 

impaired  function,  34 

local,  32 

modification  of  nutrition,  35 

muscular  rigidity,  34 

pain,  33 

referred,  33 

redness,  32 

swelling,  33 

tenderness  on  pressure,  34 
terminations,  27 
treatment,  35 

alteratives,  44 

Bier's  hyperemia,  40 

cathartics,  42 

cold,  37 

compression,  40 

constitutional,  41 

counter-irritants,  39 

diaphoretics,  43 

diet,  41 

diuretics,  43 

douches,  39 

drugs,  42 

heat,  38 

hygiene,  41 

incision,  40 

irrigation,  38 

local,  37 

bleeding,  39 

massage,  41 

narcotics,  39 

operation,  40 

position,  37 

])rophylaxis,  35 

rest,  37 

sedatives,  42 

serum  therapy,  44 

stimulants,  43 

stimulation  of  i)hagocytosis, 

tonics,  44 

vaccines,  44 

venesection,  39 
Inflammatory  fever,  71 

lymph,  24 
Infusion,  axillary,  144 
intravenous,  145 
Ingrowing  toe-nail,  260 
Inguinal  hernia,  779 

complete,  783 

direct,  792 

treatment,  793 

incomplete,  783 


44 


Inguinal  hernia,  oblicjue,  780 
j)r()peritoneal,  784 
strangulation,  784 
Inguino-('rural  hernia,  785 
Injuries,  159 

general  effec-ts,  172 
local  effects,  159 
Insect-stings,  170 
Intestinal  anastomosis,  832 
end-to-end,  833 
lateral,  834 
Murphy  button,  839 
localization,  825 
stasis,  899 
sutures,  828 

tract,  internal  fistula^,  891 
Intestine,  gunshot  wound,  845 

hemorrhage  of,  in  typhoid,  893 
obstruction,  884 
acute,  885 
chronic,  889 
diagnosis,  886 
oi)eration,  888 
treatment^,  887 
perforation  of,  suture  in,  829 

in  typhoid,  892 
resection,  831 
rupture,  843 
surgery,  884 
tumors,  894 
wounds,  830 
Intoxication,  70 
Intracerebral  hemorrhage,  570 
Intracranial  hemorrhage  in  newborn,  576 
Intradural  hemorrhage,  575 
Intrathoracic  operations,  anesthetic,  153 
Intratracheal  insufl^ation,  154 
Intravenous  transfusion,  145 
Intubation,  668 

Intussusception,  treatment,  889 
Involucrum,  426 
lodin  disinfection,  141 
Irreducible  hernia,  759 
Ischemic  contracture,  540 
Ischiatic  hernia,  801 
Ischio-rectal  abscess,  607,  903 
Italian  rhinoplasty,  621 


Jacksonian  epilepsy,  590 
Jackson's  membrane,  896 
Jacob's  ulcer,  123 
Jaw,  carcinoma,  660 

fractures,  321 

osteomyelitis,  658 

necrosis,  658 

sarcoma,  661 

surgery,  657 

tumors,  660 
Jejunum,  peptic  ulcer,  880 
Joint,  Charcot's,  460 

mice,  461 
Joints,  ankylosis,  467 

atrophic  lesions,  452 


IXDEX 


112' 


oiiits,  ('(mtusioiis,  lis") 

(iiscascs,  Aiil 

ilystropliifs,   l-')' 

i>iasii)ii,  4S() 

^imsliot  wouiids,  ISC) 

hypcrtropliic  lesions,    !.)() 

infect  ion,  -Uil,  47 1_ 
{i;»)no<'o('('i(',  47 1 
metastatic,  47!^ 
pneuniococcic,  471 

injuries,  iiS") 

loose  l)0(lies  in,  4(11 

neuropatiiic,  400 

.sarcoma,  aO.S 

syphilis,  'A)'-i 

tuberculosis,  47(1 

lumofs,  M'A 

wounds,  3S(1 


Kadkk's  jrastrostomy,  S77 
Kchr's  incision,  928 
operation,  933 
Keloid,  109 

Kelly's  cystoscope,  960 
Kidney,  anomalies,  972 
calculus,  977 
carcinoma,  983 
cyst,  984 
dislocated,  973 
floating,  973 
functional  capacity,  961 
gunshot  wound,  984 
horseshoe,  972 
hydrops,  976 
infections,  973 
injuries,  984 
movable,  972 
needling,  981 
operations,  985 

incisions,  985 
sarcoma,  983 
stab  wound,  984 
stone,  977 
surgery,  958,  972 
surgical,  975 
tuberculosis,  982 
tumors,  983 

diagnosis,  953 
Killian's  operation,  657 
Kink,  Lane's,  of  ileum,  896 
Knee,  dislocation,  412 
congenital,  515 
excision,  469 
tuberculosis,  498 
knee-joint,  amputation,  213 
Knock-knee,  421 
Knots,  166 

Kobelt's  tubules,  1099 
Kraske's  operation,  916 


Lacerated  wounds,  167 
Laceration  of  cervix,  1081 


Laceration  of  perineum,   KtS'-' 
Lacteal  calculus,  701 
Lacunar  resorption,  41(1 
liaminectomv,  601 
Lane's  kink,"s96 
Laparotomy,  MS 
Larrey's  amput;ition,  215 
Laryngectomy,  672 
Laryngo-fissure,  672 
Laryngoscopy,  668 
Larynx,  carcunoma,  668 
extirpation,  672 
fracture,  667 
intubation,  668 
])ai)illoma,  668 
tumors,  668 
Lateral  anastomosis,  834 
sinus,  567 
j  thrombosis,  577 

ventricles,  tapiiing,  555 
j  Laugier's  hcu-nia,  794 
'  Leeciiing,  147 
Lee's  amputation,  212 
Leg,  am|)utation,  212 
fractures.  376 
ulcer,  55 
Leiomyoma,  114 
Lembert  suture,  828 
Leontiasis  ossea,  424 
I  Lepidomas,  106 
j  Leptomeninges,  syphilis  of,  579 
I  Leptomeningitis,  578 
1  Leukocytosis,  31 
I  Lcuko-keratosis,  647 
,  Leukoma,  647 
Leukopenia,  31 
Leukoplakia,  647 
Ligaments,  shortening  round,  1086 

silk,  529 
Ligation,  229 

for  aneurysm,  253 
Lightning  strokes,  222 
Line  of  demarcation,  60 
Linitis,  plastic,  872 
Lip,  carbuncle,  641 
cysts,  640 
epithelioma,  641 
surgery,  634 
Lipoma,  107 

arborescens,  503 
of  breast,  713 
of  neck,  684 
Lipomatosis,  107 
Liquor  puris,  26 
Lisfranc's  amputation,  210 
Lithectasy,  970 
Litholapaxy,  970 
Lithotomy,  970 

perineal,  971 
Lithotrity,  969 
Litigation  spine,  594 
Littre's  hernia,  755 
Liver,  abscess,  936_ 
I  anomalies,  935 

I  carcinoma,  941 

cirrhosis,  940 


1128 


INDEX 


Liver,  corset,  935 

cyst,  echinococcus,  93S 

gunshot  wounds,  847 

linguiforin  lobe,  935 

Riedel's  lobe,  935 

rupture,  842 

operation,  843 

sarcoma,  942 

surgery,  935 

tumors,  941 
Lockjaw,  90 
Longitudinal  sinus,  rupture,  563 

thrombosis,  577 
Ludwig's  angina,  645 
Lumbar  abscess,  607 

hernia,  779 
Lumpy  jaw,  85 
Lung,  abscess,  748 

decortication,  745 

gangrene,  748 

hernia,  736 

injuries,  733 

surgery,  669,  733 

tuberculosis,  747 

tumors,  749 
Lupus  vulgaris,  263 

of  cheeks,  624 
Luxations,  387 
Lymph,  inflammatory,  24 
Lymphadenitis,  269 

of  neck,  674 

tuberculous,  676 
Ly  mphangeio-endothelioma,  1 28 
L3'mphangeioma,  270 
Lymphangeioplasty,  270 
Lymphangeitis,  268 
Lymphangiectasis,  269 
Lymphatic  varicocele,  269 
Lymphatics,  wounds,  268 
Lymphedema,  270 
Lymphization,  23 
Lymphocytes,  origin,  22 
Lymphoma,  114 

sarcomatodes,  272 
Lymphomatosis,  114,  271 
Lymphorrhea,  268 
Lymphosarcoma,  116,  272 
Lj^ssa,  96 

M 

McBitrney's  incision,  820 

point,  820 
Macrocheilia,  640 
Macroglossia,  644 
Macromelia,  270 
Madelung's  deformity,  542 
Madura  foot,  86 
Malar  bone,  fracture,  320 
Malignant  lymphoma,  271 

pustule,  87 
Mallein  test,  90 
Mammary  abscess,  701 
chronic,  701 

gland.    S(e  Breast. 
Mandible,  dislocation,  391 


Mandible,  excision,  662 
fracture,  321 
tumors,  660 
Mania  a  potu,  174 
Manus  valga,  542 
Marginal  ion,  20 
Marjolin's  ulcer,  123 
Mastitis,  acute,  700 

carcinomatous,  719 
chronic,  702 

cystic,  706 
stagnation,  700 
.sj'philitic,  704 
Mastodynia,  702 
Mastoiditis,  acute,  630 
operation,  632 
Matas's  operation,  257 
Mattress  suture,  831 
Maunsell's  operation,  834 
Maxilla,  excision,  662 
fracture,  321 
tumors,  660 
Mayo  Robson's  incision,  820,  928 
Mayo's  operation,  244 
Meckel's  diverticulum,  891 
Mediastinitis,  732 

Mediastinum,  anterior,  surgery  of.  732 
Medio-tarsal  joint,  amputation,  211 

dislocation  of,  415 
Megacolon,  congenital,  900 
Melanoma,  129 
Melon-seed  bodies,  478 
Meloplasty,  624 

Meninges,  surgical  affections  of,  567 
Meningitis,  578 
amicrobic,  579 
epidemic  cerebrospinal,  578 
serous,  579 
^  spinal,  618 

j  tuberculous,  579 

j  meningocele,  553,  592 

Meningomyelocele,  592 
!  ISlercier  catheter,  1034 
Merocele,  793 
Mesenteric  cysts,  895 
embolism,  890 
thrombosis,  890 
Mesosigmoiditis,  898 
Mesothelioma,  127 
Metacarpal  amputation,  206 
Metacarpus,  dislocation,  404 

fracture,  361 
Metastatic  abscess,  73 
Metatarsalgia,  anterior,  547 
Metatarsus,  dislocation,  415 

fracture,  384 
Metritis,  1074 
acute,  1074 
chronic,  1075 
septic,  1094 
Michel's  clamps,  166 
Microcephalus,  554 
Microdactylia,  275 
Micrognathy,  659 
Middle  meningeal  hemorrhage,  575 
Migration,  20 


IXDEX 


1120 


Mikulicz's  (lis(>asc,  ()2() 
■  Miner's  elbow,"  2()7 
Minor  sin^ery,  142 
Mixed  clwineie,  991 

tumors,  1()() 
Muleculiir  ileath,  .VJ 
Molluscuin  lihrosuni,  "-'915 
Moiiibur^'s  lieinostasis,  "JHi 
Moiiorcliiilism,  1050 
Morbus  coxa;  senilis,  45() 
Mortification,  5S 
MosetiK-Moorhof  bone-wax,  485 
"Mother's  mark,"  244 
Mouth-wash,  iodo-glvcerolc,  (152 
Movable  kidney,  972' 

spleen,  955 
Mucous  patches,  995 
Mummery's  operation,  910 
Murphy  button,  S.39 
Muscle,  congenital  alisence,  505 

contracture,  27G 

rupture,  274 

tumors,  277 

\v(junds,  273 
Muscular  hernia,  274 
Myelogenous  leukemia,  113 
Myeloma,  113 

giant-celled,  113 
Myelomatosis,  113 
Myocarditis,  postoperative,  177 
Myorua,  114 

malignant,  110 

of  uterus,  1102 

sarcomatofles,  116 
Myomectomy,  1106 
Myo-sarcoma,  116 
Myositis,  274 

ossificans  progressiva,  275 
traumatica,  274 

traumatic,  274 
Mj'ringotom}',  630 
Myxedema,  688 
Myxo-lipoma,  108 
Myxoma,  109 
Myxo-sarcoma,  109 

N 

Nasal  bones,  fracture,  320 
Naso-pharjmx,  tumors,  665 
Neck,  deformities,  537 

fibroma,  684 

ligneous  phlegmon,  673 

lipoma,  684 

lymphadenitis,  674 

operations,  anesthetic,  153 

surgery,  673 

woody  phlegmon,  673 

wounds,  673 
Necrosis,  58,  431 

jaws,  658 

liquefaction,  59 
Needles,  164 

operative,  removal  of,  169 
Needling  kidney,  981 
Negri  bodies,  97 


iNelaton's  line,  3()4 
Neoplasm.    Sec  Tumors. 
Nephrectomy,  987 
Nephritis,  .sejjtic,  974 

toxic,  974 
Ncplu'olithiasis,  977 

simple,  978 

treatment,  9S0 
Nei)hrolithotomy,  980 
Nephropexy,  973,  987 
Nephroptosis,  972 
Nephrr)tomy,  980,  986 
Nerve  aiiiistomosis,  286 
for  talipes,  527 

blocking,  157 

contusion,  2S2 

dislocation,  283 

gunshot  wounds,  186 

laceration,  283 

regeneration,  287 

rupture,  282 

stretching,  283 

tumors,  293 

woimds,  284 
Nervous  system  in  inflammation,  27 
Neuralgia,  288 

of  breast,  702 

sciatic,  292 

trifacial,  289 
Neuralgic  ulcer,  54 
Neurectasis,  288,  292 
Neurectomy,  288 
Neurinomas,  293 
Neuritis,  287 
Neurofibromatosis,  293 
,  Neurolysis,  288 
I  Neuroma,  114 
]  amputation,  114 

false,  114 
Neuropathic  joints,  460 
Neuroplasty,  286 
Neurorrhaphy,  285 
I  Neurotomy,  288 
j  intra-perineural,  530 

Nevoid  lipoma,  246 
Nevus  pilosus,  245 

vasculosus,  244 
Newborn,  intracranial  hemorrhage,  576 
Nipple,  affections,  699 

excoriation,  700 

fissures,  700 
Paget's  disease,  719 
j  Nitrous  oxide  anesthesia,  152 
I  Noma,  63 
;  pudendi,  63 

j  Nou-union  in  fractures,  316  - 
I  Nose,  acne  rosacea,  620 
foreign  bodies,  620 
I  saddle,  620 

j  surgery  of,  619 

Nose-bleed,  619 


Obstruction,  choledochus,  928 
intestinal,  884 


1130 


INDEX 


Ohsti'iiction,  intestinal,  Jicute,  SS") 
treatment,  887 
chronic,  889 

pyloric,  868 
Obturator  hernia,  799 
Ochsner  treatment,  811 
Odontomas,  112 
Olecranon,  fractin'e,  348 
Omentum,  cyst,  895 
Omphalectomy,  777 
Onychauxis,  260 
Onychia,  260 
Oophorectomy,  1080 
Oophoritis,  1078 
Operation,  818 

ablation  of  breast,  721 

adenectomy,  077 

Agnew's,  506 

air  passages,  668 

Alexander's,  1086 

amputations,  192 
bi'east,  710 

anastomosis,  intestinal,  832 

Anel's,  for  aneurysm,  254 

anesthesia,  148 

anem-ysmoplasty,  258 

ante-thoracic    esophago-jejuno-gas- 
trostomy,  696 

Antyllus,  255 

appendicectomy,  855 

appendicostomy,  896 

arthrectomy,  486 

arthrodesis,  528 

arthroplasty,  471 

astragalectomy,  521 

Ashhurst's  amputation,  212 
excision,  469 

Bassini's,  787 

Beck's,  1044 

Berger's,  210 

bile-duct,  928 

Billroth's  amputation,  216 
gastrectomy,  881 

Bottini's,  1036 

"Bottle,"  1060 

Brasdor's,  for  aneurysm,  255 

castration,  1056 

cecostomy,  896 

cholecystectomy,  931 

cholecystendysis,  930 

cholecystenterostomy,  934 

cholecysto-duodenostomy,  934 

cholecysto-gastrostomy,  934 

cholecystostomy,  930 

cholecystotomy,  930 

choledocho-enterostomy,  928 

choledochostomy,  932 

choledochotomy,  932 

chondrectomy,  748 

Chopart's  amputation,  211 

cleft  Dalate,  638 

Cock's,  1025 

colostomy,  915 

colpo-perineorrhaphy,  1083 

colporrhaphy,  1083 

craniotomy,  586 


Operation,  Cushing's  decompressive.  590 
cystocele,  1088 
cystotomy,  970 
Demarquay's,  1018 
Didot's,  506 
Dudley's,  1070 

Dupuytren's  ami)utation,  209 
endo-aneurysmorrhaphy,  257 
epiploi)ex3',  941 
erasion  of  joints,  486 
esophagotomy,  694 
Estlander's,  746 
excision,  ankle,  500 

elbow,  470 

hip,  497 

knee,  469 

mandible,  662 

shoulder,  470 

superior  maxilla,  062 

of  tongue,  651 

tumors  in  general,  131 

urethral  stricture,  1018 

wrist,  470 
extirpation,  aneurysmal  sac,  256 
Finney's  pyloroplasty,  879 
Frazier-Spiller,  292 
gastreetomj^  881 
gastro-anastomosis,  872 
gastrogastrostomy,  872 
gastrojejunostomy,  879 
gastroplasty,  871 
gastrostomy,  877 
gastrotomy,  876 
Gersuni's,  910 
goitre,  687 

Gritti's  amputation,  213 
Guthrie's  amputation,  214 
Hancock's  amputation,  211 
hemilarj'ngectomy,  672 
hepatico-enterostomy,  928 
hernia,  787 

Hey's  amputation,  210 
Hunter's,  for  aneurysm,  254 
hj'sterectomj',  1 106 
hj'steropex}^  1086 
intestinal  anastomosis,  832 
Kader's  gastrostomy,  877 
kidney,  985 
KiUian's,  657 
Kraske's,  916 
laminectomy,  001 
laparotomj^,  818 
LaiTey's  amputation,  hip,  215 

shoulder,  209 
LeConfe's  amputation,  210 
Lee's  amputation,  212 
Ligation  for  aneurj'sm,  254 

of  arteries,  230 
Lisfranc's  amputation,  210 
lithectasy,  970 
litholapaxy,  969 
lithotomy,  970 
lithotrity,  969 
Littre's,  902 

Matas's,  for  aneurysm,  257 
JNlaunsell's,  834 


IXDKX 


1131 


Opcnitioii,  Mayo's,  2-H 
Muiiiinciy's,  iUO 
iu'plin'<'t(iiny,  'J.S7 
neplirulithotoiny,  !>S() 
ni'ijliropcxy,  OS? 
nephrotomy,  980 
neurectomy,  2.SS 
neurorrhaphy,  '2S't 
neurotomy,  2S.S 
omphalectomy,  777 
oophorectomy,  1080 
orcliidectomy,  lOoO 
orchidopexy,  lO.il 
osteophistic,  504 
osteotomy,  420 
ovariotomy,  629 
pancreatectomy,  9.51 
paracentesis  for  ascites,  940 
Peck's,  916 
pericardiotomy,  237 
perineal  section,  1024 
peritonitis,  862 
pharvngotomv,  664 
Phelps's,  520 
phlebectomy,  244 
phlebotomy,  147 
Pirogoff's  amputation.  211 
pleurotomy,  742 
pneumonectomy,  747 
pneumonotomv,  747 
Pozzi's,  1070 
proctotomy,  912 
prostatectomy,  1036 
prostatotomy,  1036 
pyelotomy,  980 
pylorectomy,  881 
pyloroplastj',  878 
rhinoplasty,  620 
Ruggi's,  797 
salpingectomy,  1080 
salpingo-oophorectomv,  1079 
Schede's,  243 
Schomacker's,  910 
Schroeder's,  1073 
Sedillot's  amputation,  212 
Senn's  amputation,  215 
sequestrotomv,  433 
Siter's,  1036  ' 
Skey's  amputation,  210 
skin-grafting,  224 
Spence's  amputation,  209 
splenectomy,  957 
Stamm's  gastrostomy',  877 
staphylorrhaphy,  638 
Stokes's  amputation,  213 
stomach,  876 
SjTne's  amputation,  211 
urethrotomy,  1022 
sjinpathectomy,  692 
Teale's  amputation,  207,  212 
tenotomj-  for  talipes,  519 
Terrier's,  932 
Textor's  amputation,  211 
Thomas's  plastic  resection  of  breast, 

711 
thoracoplasty,  746 


Operation,  thoracotomy,  712 

thyroidectomy,  692 

thyrotoniN',  672 

tongue.  (■»,53 

tracheloplasfy,  lOSl 

trachelorrhaphy,  1081 

tracheotomy,  670 

Trendelenburg's,  243 

tre|)hining  skull,  563 

uraiKjplastj',  638 

ureterolithotomy,  981 

urethrotomy,  1022 

vaginal  hysterectomy,  1108 

ventro-fixation  of  uterus,  1087 

Wardrop's  for  aneury.sm,  255 

Warren's,  711 

Whitehead's,  hemorrhoids,  908 
tongue,  653 

wiring  aneurj-sm,  256 

Witzel's  gastrostomy,  877 

Young's,  1041 
Opsonic  index.  45 

theory,  44 
Opsonins,  23 
Orchidectomy,  1056 
Orchidopexv,  1051 
Orchitis,  10o2 
Orthopedic  surgerv,  504 
0.steitis,  426 

deformans,  423 

fibrous,  437 
Osteo-arthritis,  452 

metabolic,  452 
Osteoclasis,  420 
Osteogenesis  imperfecta,  416 
Osteoma,  111 

malignant,  447 

sarcomatodes,  447 
Osteomalacia,  423 
Osteomyelitis,  426 

albuminous,  429 

chronic,  431 

jaw,  658 

ribs,  732 

treatment,  428 

vertebrae,  602 
Osteophyte,  112 
Osteoplastic  craniotomy,  586 

operations,  504 
Osteoporosis,  416 
Osteopsathyrosis,  416 
Osteosarcoma,  116,  447 
Osteotomy,  420 

for  ankylosis,  468 

subtrochanteric,  487 
Othematoma,  629 
Otitis  media,  629 
Ovariotomj',  1101 
Ovaritis,  1078 
Ovary,  abscess,  1078 

cyst,  1097 

dermoid,  1101 
retention,  1097 

cystadenoma,  1098 
papuliferous,  1098 

embryomas.  1101 


1132 


INDEX 


Ovary,  teratoma,  1101 
tumors,  1101 

diagnosis,  953 


Pachymeningitis,  578 
Paget's  disease  of  bone,  423 

of  nipple,  719 
Painful  heel,  549 
Palate,  perforations  of,  640 
Palmar  abscess,  279 

fascia,  contracture  of,  542 
Palsy,  brachial  birth,  783 

cerebi'al,  530 

crutch,  282 

infantile,  521 

post-anesthetic,  282 
Panaris,  279 
Pancreas,  abscess,  946 

carcinoma,  950 

operation,  951 

cysts,  952 

fistula,  946 

gangrene,  946 

gunshot  wounds,  847 

infections,  943 

surgery,  943 
Pancreatectonw,  951 
Pancreatic  calculi,  949 

insufficiency,  947 

lymphangeitis,  946 

reaction,  948 
Pancreatitis,  acute,  944 

chronic,  946 

treatment,  949 

hemorrhagic,  944 
Pancreato-enterostomj^  951 
Pan-hysterectoim%  1106 
Papilloma,  118 

of  bladder,  966 

intracj'stic,  118 

of  larynx,  668 
Papillomatous  growths  of  scalp,  553 
Paralytic  talipes,  521 
Paraphimosis,  1048 
ParathjToids,  691 
Paronvchia,  279 
Parotid  bubo,  624 

tuberculosis,  625 

tumors,  625 
Parotitis,  infectious,  624 

symptomatic,  624 
Parovarian  cyst,  1099 
Partridge's  hernia,  794 
Patella,  dislocation,  279 

fracture,  372 
Peck's  operation,  916 
Pectineal  hernia,  794 
Pelvic  abscess,  1077,  1096 

bones,  fractm-e,  323 

cellulitis,  1094 
Pelvi-rectal  abscess,  904 
Pelvis,  bimanual  examination,  1068 

static  disorders,  535 


Penis,  amputation,  1050 

carcinoma,  1049 

congenital  deformities,  1043 

extirpation,  1050 

surgery,  1043 
Peptic  ulcer  of  jejunum,  880 
Perforating  ulcer,  261 
Perforation  of  gall-bladder,  921 

of  intestine,  829 
typhoid,  892 

of  uterus,  1093 
Periarthritis,  466 
Pericarditis,  cardiolysis  in,  237 
Pericardiotomy,  237 
Pericholecystitis,  920 
Pericolitis,  896 

sinistra,  897 
Perimetritis.  1094 
Perineal  liernia,  800 

prostatectomv,  1040 
Perineoi)lasty,  1083 
Perinephric  abscess,  977 
Pei'ineum,  laceration,  1082 
Perinorrhaphy,  1083 
Pei'iosteal  sarcoma,  447 
Periosteitis,  acute,  425 

alveolar  border,  660 

chronic,  425 
Perisigmoiditis,  897 
Perithelioma,  128 
Peritoneal  adhesions,  814 
Peritoneum,  802 

tuberculosis,  815 
Peritonitis,  802 

acute  diffuse,  806 
local,  805 

causes,  803 

clinical  course,  805 

diffuse,  804 

operation,  862 

distention,  808 

fibrino-purulent,  804 

general,  806 

hemorrhagic,  805 

idiopathic,  803 

Ochsner  treatment,  811 

operation,  862 

pathology,  803 

pneumococcic,  815 

rigidity,  806 

septic,  805 

spreading,  804 

starvation  treatment,  811 

sj^mptoms,  805 

tenderness,  808 

toxic,  805 

treatment,  810 
Peritonsillar  abscess,  663 
Peri-urethral  abscess,  1027 
Pernio,  222 
Pes  planus,  547 
Petechia,  159 
Phagedenic  ulcer,  54 
Phagocj-tes,  23 
Phagocytosis,  23 
Phalanges,  dislocation,  404 


IM)KX 


1133 


Phalann(-s,  fracliirc,  3()'_',  3S4 
Plianiifiotoiny,  lateral,  ()(>  I 

siihliyoid,  (Wi") 

SMi)raliy()i(l,  (i(t  I 
Pliolps's  ()|)<Mati<)ii,  .")L'(1 
I'lifiiol-siilplioMcplitlialciii  tcsl,  '.Mil 
IMiiiiiosis,  104') 

froatiiu'iil,  10  U) 
Phl('l)(>ctasis,  •J12 
riilchoctoiny,  244 
I'hlchitis,  2;ls 

post-optTalivc,  240 

Iroat incut.  240 
Phl.'holiths,  2;W 
l'hlch()scl(>r()si.s,  28.S 
Plil(4)otoiiiy,  147 
PiilcKiiioii,  2(5,  47 

Phosphorus  jioisoninf;;,  hones  in,  (558 
Picric  acid  dressing;,  219 
Pijinicntod  mole,  24.") 
Piles.  !)()() 
Pilo-nidal  cyst,  2()() 

fistula,  2()6 
PiroRoff's  amputation,  211 
V.  Pirquot's  test,  81 
Plaster  jacket,  610 
Piaster  of  Paris,  137 
Plastic  linitis,  872 

surgery,  225 
Pleura,  disci.ssion,  74G 

injuries,  733 

surgery,  733 

tuberculosis,  746 

tumors,  749 
Pleural  fistula,  744 
Pleurisy,  739 
Pleuritis,  739 
Pleurotomy,  742 
Plexiform  neuroma,  293 
Plombage,  435 
Pneumococcic  joint  infection,  471 

peritonitis,  815 
Pneumo-hemothorax,  738 
Pneumonia,  post-operative,  177 
Pneumonectomy,  747 
Pneumonotomy,  747 
Pneumothorax,  737 
Points  douloureux,  289 
Poisoned  wounds,  170 
Poliomj^elitis,  anterior,  521 
Polvdactylism,  505 
Polymastia,  699 
Polypus,  naso-pharyngeal,  665 

rectal,  913 

uterus,  1103 
Polythelia,  699 
"Port-wine"  stauj,  244 
Post-anesthetic  palsj',  282 
Post-operative  deaths,  176 

embolism.  178 

fat-embolism.  178 

heat  prostration,  179 

mvocarditis.  177 

phlebitis,  240 

pneumonia,  177 

sepsis,  177 


I'ost-operativc  status  Ivniphaticus,  178 
Pott's  di.scase,  602 

abscess,  606 

treatment,  613 
contractures,  treatment,  614 
()l)erativ(!  fixation  of  spine.  61'J 
I)arai)legia,  608 
treatment,  609 

fracture,  380 
Pozzi's  operation,  1070 
Pre-cancerows  changes,  121 
Pregnancy,  extra-uterine.  1090 

treatment,   1092 
Prepuce,  atlherent,  1046 

redundanciy,  1046 
Probe,  eyed,  49 
Procidentia  recti,  909 

uteri,  1088 
Proctitis,  910 
Proctoclysis,  144 
Proctoscope,  901 
Proctotomy,  912 
Profeta's  law,  999 
Prolapse  of  rectum,  909 

of  urethra.  1018 

of  uterus,  1088 
Properitoneal  inguinal  hernia,  784 
Prostate,  abscess,  1028 

adenomatosis,  1030 

atrophy,  1041 

carcinoma,  1042 

enlargement,  1029 
operation,  1036 
treatment,  1034 
radical.  1036 

hypertrophy,  1029 

sarcoma,  1042 

surgery,  1028 
Prostatectomy,  1036 

perineal,  1040 

suprapubic,  1038 
Prostatotomy,  perineal,  1036 
Prostatitis,  acute,  1028 

chronic,  1028      ' 
"Proud  flesh,"  53 
Psammoma,  128 
Pseudoleukemia  infantium,  957 
Psoas  abscess,  607 
Ptomains,  19 
Pudendal  hernia,  800 
Puerperal  pyemia,  1093 

sepsis,  1092 
"Pulled  elbow,"  403 
Pulmonary  embolism.  178,  241 

<)steo-arthro))athy,  475 
Punctured  wounds.  169 
Pus,  25 

absorption,  26 

encapsulated.  26 

gummatous,  84 
Pus- tube,  1076 

rupture,  1077 
Py arthrosis.  462 
Pyelitis.  974 
Pyelo-nephritis.  974 
Pyelotomy,  980 


1134 


INDEX 


Pyemia,  73 

puerperal,  109G 

symptoms,  74 

treatment,  74 

tuberculous,  <S() 
Pylorectomy,  S81 
Pyloroplasty,  878 

riimey\s,  879 
Pylorospasm,  869 
Pylorus,  obstruction,  868 

stenosis,  869 
Pyogenesis,  25 
Pyogenic  bacteria,  28 

membrane,  26 
Pyonephrosis,  977 
Pyosalpinx,  1076 
Pyothorax,  739 
Pyrexia,  70 


Quinsy,  663 


Rabies,  96 

Racemose  aneurysm,  247 
Rachitic  rosary,  726 
Rachischisis,  592 
Rachitis,  417 

osteoclasis,  420 

osteotomy,  420 
Radio-carpal  joint  dislocation,  403 
Radius,  fracture,  350 

head  of,  dislocation,  402 
Railway  sjjine,  594 
Rankenneurom,  293 
Ranula,  645 
Ray  fungus,  84 
Raynaud's  disease,  64 
V.  Recklinghausen's  disease,  293 
Rectocele,  1082 
Recto-genital  fistula,  913 
Recto-urethral  fistula,  913 
Recto-urinary  fistula,  913 
Recto-uterine  fistula,  913,  1089 
Recto-vaginal  fistula,  913 
Rectum,  adenoma,  913 

carcinoma,  913 

false  anus,  914 
radical  ojieratioii,  915 

examination,  900 

malformations,  901 

polypus,  913 

prola]jse,  909 

stricture,  911 

surgery,  900 

tumors,  913 
Redr(>ssement  force,  519 
Regeneration,  30 
Renal  calculus,  977 

colic,  979 
Repair,  29 

in  fractures,  303 

in  incised  wounds,  161 
Resection  of  breast,  711 


I  Resection  of  intestine,  831 
Residual  i)eritoneal  abscess,  813 
Restitutio  ad  integrum,  30 
Retained  secundines,  1093 
Retention  of  urine,  1015 
Retroflexion  of  the  uterus,  1086 
Retrognathism,  ()59 
Retrograde  catheterization,  1025 
Retroversion  of  the  uterus,  1086 
j  Reverdin's  skin-grafting,  224 
'Rhabdomyoma,  106,  114 
!  Rhagades,  1000 
Rheumatic  arthritis,  473 
Rheumatism,  tuberculous,  474 
"Rheumatisme  noueux,"  452 
Rheumatoid  arthritis,  452 
Rhinoplasty,  620 
j  Rhinoscleroma,  87 
j  Rhizotomy,  530 
I  Ribs,  caries,  73 1 
I  cervical,  539 

I  fracture,  323 

osteomyelitis,  732 
Richter's  hernia,  755 
I  Riedel's  lobe,  935 
i  Ring  fracture,  559 
Rodent  ulcer,  123 
of  cheeks,  624 
Roller  bandage,  133 
Rose  ulcer,  717 

Round  ligaments,  shortening  of,  1086 
Rupture  of  abdominal  wall,  840 
bladder,  971 
diaphragm,  750 
gastro-intestinal  tract,  842 
heart,  236 
liver,  842 
muscle,  274 
nerve,  282 
pus-tube,  1077 
spleen,  842 
tendon,  27N 
urethra,  1017 


St.  Anthony's  fire,  67 
"Habre-blade  deformitv,"  442 

tibia,  1000 
Saccular  aneurysm,  249 
Saci'o-iliac  joint,  dislocation,  405 

tuberculosis,  502 
Saddle  nose,  620  ^ 

Saline  solution,  143 
Salivary  calculus,  627 

fistula,  626 

glands,  surgery,  624 
Salomon's  test,  948 
Salpingectomy,  1080 
Salpingitis,  1075 
Salpingo-oophorectom  V,  1 079 
Sajiremia,  71,  75,  1093 

chronic,  75 
Sarcocele,  1056 
Sarcoma,  114 


ISDEX 


11:^.5 


Sarcnina,  alveolar,  1  !•') 
bono,  AA{\ 
(if  brain,  'iSj 
of  breast,  713 
classification.  11") 
niant-celle"!.  1 13 
of  jaw,  <'»<>1 
of  joint,  0(13 
of  kidney,  !>S3 
larse  round-celleil,  1 1') 
of  liver,  <)42 
inodullarv,  AM 
mixed-celled,  115 
osteoid,  447 
jieriosteal,  447 
of  prostate,  1042 
jniro,  110 
of  scalp,  ")53 
small  round-eellcd,  115 
spindle-celled,  115 
of  thyroid,  0!)2 
of  tonsil,  ()<)4 
tubular,  115 
Sarco-sepsis,  71 
Scalds,  217 

Scalp,  birth-injuries,  561 
contusions,  551 
cyst,  dermoid,  553 
epithelioma,  553 
papillomatous  growths,  553 
sarcoma,  553 
surgical  affections,  551 
tumors,  553 
wounds,  552 
Scajiula,  congenital  elevation,  514 
dislocation,  394 
fracture,  330 
Scar  tissue,  24 
Schede's  operation,  243 
thoracoplasty,  746 
Schmidt's  test,  948 
Schomacker's  operation,  910 
Schroeder's  operation,  1073 
Sciatica,  292 
Scirrhus  of  breast,  715 
Sclavo's  serum,  89 
Scoliosis,  531 

treatment,  533 
Scrofula,  76 
Scrofuloderma,  264 
Scrotmn.  elephantiasis,  1062 
epithelioma,  1063 
papilloma,  1063 
tumors,  1063 
Scurvy,  423 
Sebaceous  cyst,  265 
Semilunar  cartilage,  subluxation,  412 
Sedillot's  amputation,_212 
Semino-vesiculitis,  1054 
Senile  arthritis,  456 
Senn's  amputation,  215 
gastrostomy,  877 
powder,  219 
Sejjsis,  36,  70 

post-operative,  177 
puerperal,  1092 


Sei)tic  diarrhea,  806 
nephrit  is,  974  ^ 
peritonitis,  805 
Septicemia,  71 

puerperal,   1094 
Seciuestrotomy,  433 
Setiuestrum,  426 
;  Sera,  45 

Sero-serous  suture,  828 
Serpiginous  ulceration,  53 
Serum,  antistreptococcic,   \.> 
I  therapy  in  inflammation,  4  1 

I  Shock,  172 

electric,  222 
erethistic,  173 
insidious,  173 
prevention,  174 
psychical,  173 
secondarj',  173 
torpid  stage,  173 
treatment,  175 
Shoulder  dislocation,  394 
congenital,  513 
excision,  470 
;  Shoulder-joint,  amputation,  207 
;  Sialo-Uthiasis,  627 
I  Sigmoid  diverticulitis,  897 
I  hernia,  785 

surgery,  895 
tumors,  913 
Sigmoiditis,  897 
Sigmoidopexy,  910 
Sigmoidoproctostomy,  912 
Silicate  of  sodium  dressing,  139 
Silk  ligaments,  529 
Silverfork  deformity,  351 
Simple  ulcer,  54 
Simpson  splint,  619 
Sims's  position,  1064 

speculum,  1065 
Sinus,  48,  52 

thrombosis,  577 
treatment,  52 
tuberculous,  80 
Sinusitis,  655 
frontal,  656 
maxillary,  656 
Siter's  operation,  1036 
Skey's  amputation,  210 
Skiagraphy  in  fractures,  302 
Skin,  surgery,  259 
Skin-grafting,  57,  223 

Reverdin's  method,  224 
Thiersch's  method,  223 
Wolfe-Krause  method,  225 
Skull,  caries,  439 

congenital  malformations, 

553 
dangerous  area,  567 
fi-actures,  557 
base,  564 
bm-sting,  558 
by  count  erst  roke,  558 
ring,  559 
treatment,  561 
vault,  559 


1136 


INDEX 


Skull,  injuries,  557 

newborn,  fracture,  564 

osteomyelitis,  566 

surgical  affections,  553 

temporar}'  resection,  586 

trephining,  563 

wounds,  557 
Sliding  hernia,  785 
Sloughing,  58 

phagedena,  63 

ulcer,  54 
Small-shot  wounds,  185 
Smoker's  patches,  647 
Snake  bites,  170 
Snapping  hij:),  546 
Sounds,  urethral,  1015 
Spasmodic  tic,  292 

torticollis,  292 
Speculum  examination,  1065 
Spermatocele,  1061 
Spermato-cystitis,  1 054 
Sphacelus,  58 
Spina  bifida,  592 

anterior,  592 
occulta,  592 

ventosa,  113 
Spinal  anesthesia,  157 

cord,  concussion,  594 

meningitis,  618 
Spine,  dislocation,  594 

fractures,  594 

gonococcic  infections,  615 

gunshot  wounds,  189 

injuries,  593 

lateral  curvature,  531 

lumbar  static  disorders,  535 

pneumococcic  infection,  615 

sprain-fracture,  594 

stab  wounds,  594 

strains,  593 

surgery,  592 

tuberculosis,  602 

tumors,  617 
Spirochseta  pallida,  82 
Spleen,  abscess,  955 

cysts,  955 

dislocated,  955 

enlargements,  954 

gunshot  wounds,  847 

movable,  955 

rupture,  842 

operation,  844 

surgery,  953 

tumors,  953 
Splenectomy,  957 
Splenic  anemia,  955 
Splenomegaly,  955 
SpondA'litis,  atrophic,  615 

deformans,  615 

hypertroi)hic,  616 

traumatic,  602 

typhoid,  615 
Spondylolisthesis,  536 
Spondvlose  rhizomelique,  617 
Sprain,  385 
"Sprained  ankle,"  385 


Sprain  fracture,  298 

of  spine,  594 
Sprengel's  deformity,  514 

incision,  928 
Squirrhe  en  cuirassc,  717 
Stab  wounds,  170 

of  abdomen,  844 
of  diaphragm,  749 
of  spine,  594 
of  thorax,  733 
Stagnant  gall-bladder,  922 
Stamm's  gastrostomy,  877 
Staphyk)rrhaphy,  638 
Starch  dressing,  139 
Stasis  cyanosis,  727 
Status  h'mphaticus,  178 
Steatoma,  265 
Steatorrhea,  947 
Stenosis  of  cervix,  1070 
Sterilization,  140 
Sterno-clavicular  dislocation,  392 
Sternum,  fracture,  322 

tuberculosis,  732 
Still's  disease,  474 
Stomach,  carcinoma,  873 
cirrhosis,  872 
dilatation,  acute,  869 

secondary,  870 
fibromatosis,  873 
gunshot  wounds,  846 
hour-glass,  871 
linitis,  872 
operations,  876 
.segmented,  871 
surgerv,  864 
ulcer,  864 

acute,  865 
chronic,  865 
hemorrhage,  868 
open,  865 
operation,  867 
perforation,  867 
treatment,  866 
Strains,  back,  593 

tendon,  279 
Strangulated  hernia,  761 
Strangulation,  160 
Strapping,  385 
Strawberr}'  gall-bladder,  922 
Stricture  of  esophagus,  695 
of  rectum,  911 
of  urethra,  1018 
Strumitis,  688 
Stumps,  (iisea,ses  of,  200 
end-bearing,  202 
structure,  200 
Stj'ptics,  229 
Subastragalar  amputation.  211 

dislocation,  415 
Subcranial  abscess,  578 

hemorrhage,  574 
Subinvolution  of  uterus,  1086 
Subluxation  of  jaw,  392 

semilunar  cartilage,  412 
wrist,  spontaneous,  542 
Submammarv  abscess,  702 


INDEX 


1137 


Subpectorul  ahscpss,  730 
Suhscripular  abscess,  731 
Siibtiocliiiiitcric  osteotomy,  AS7 
Subuiimial  (>xost<»sis,  444 
SupernuiiHTary  tinners,  oO") 

toes,  'lO'i 
Sui>piiratioii,  '2'i 

without  bacteria,  27 
Suprapubic  fistula,  MYMi 

pn)statectoiiiy,  HY.iS. 
Suprascapular  abscess,  731 
Supravesical  hernia,  7!)J 
Sur>iical  fever,  71 

infections,  70 

kidney,  97') 

technique,  133 
Sutures,  162 

absorbable.  162 

Alb.nt-I.enibert.  829 

Iniricd,  ir)3 

chain.  163 

C'onnell's,  .S34 

Cushing's,  831 

Czerny's,  829 

deep.  163 

Dupuvtren's,  831 

Gelv's,  829 

Halsted's,  831 

hare-lip,  636 

interrupted,  162 

intestinal,  828 

knots,  166 

Lembert,  828 

lock,  163 

mattress,  831 

Mayo's,  837 

non-absorbable.  162 

overhand,  163 

quilled.  163 

quilt,  163 

sero-serous,  828 

subcuticual  .  16") 

superficial,  163 

through-and-through,  829 

tongue  and  groove,  621 

twisted,  636 
SjTne's  amputation,  211 

operation,  1022 
Symmetrical  gangrene,  64 
Sjinpathectomy,  692 
Syncope,  173 
Syndactylism,  506 
Synovitis,  462 

'chronic  serous,  462 

treatment,  463 
Syphilis,  989 

bone,  440 

breast,  704 

chancre,  83 

complement-fixation  test,  1001 

condj'lomata  lata,  995 

contagion,  989 

diagnosis,  1001 

gummas,  84 

hereditary,  998 

insontium,  989 
72 


Sv 


S\ 


philis,  joint,  503 

Iej)tomeninges,  579 

mucous  patches,  995 

pathology,  83 

I)eriod  of  incubation,  83 

pregnancy.  999 

rashes,  995 

salvarsan,  1005 

.secondarv  lesions,  83,  993 

skin  l«-si(".ns,  996 

symptoms,  first  stage,  9!M) 
second  stage,  !(!)3 
third  stage,  996 

tertiarv,  996 

testicle,  1056 

tongue,  649 

treatment,  1002 

treponema  pallidum.  1001 

Wassermann  test,  1001 
philitic  })ubo,  992 

dactvlitis,  99S 

panaris,  998 

rupia,  996 

tubercle,  996 
I)hilodermas,  83,  994 
philoma.  brain,  581 
ringomyelia,  461 
ringomyelocele,  592 


Talbot's    iodo-gljcerole    mouth    wash, 

652 
Talipes,  congenital,  515 

nerve  anastomosi.s,  527 

paralytic,  521 

tenotomj'  in,  519 
Tarsus,  dislocation,  414 

fracture.  382 

tuberculosis,  500 
Telangiectases,  244 

Temporo-maxillarj-  joint  ankylosis,  659 
Tendon-sheaths,  tuberculosis,  279 
Tendons,  dislocation,  278 

gunshot  wounds,  186 

rupture,  278 

strains,  279 

transplantation,  525 

wounds,  277 
Tenotomy  for  talipes,  519 
Tenosynovitis,  279 
Terato-blastoma,  105 
Teratomas,  104 

monsters,  105 

fetal  inclusion,  105 

ovary.  1101 

sacral,  106 
Terrier's  operation,  932 
Tessier's  hernia,  794 
Testicle,  congenital  anomalies,  1050 

gumma,  1057 

inflammation,  1052 

misplaced,  1050 

neoplasms,  1057 

neuralgia,  1054 


1138 


IXDEX 


Testicle,  non-descent,  1050 

sarcoma,  1058 

surgery,  1050 

syphilis,  1056 

torsion,  1052 

tuberculosis,  1054 

tumors,  1057 

wandering,  1050 
Tetanus,  90 

antitoxin,  94 

carbolic  acid  injections,  96 

chronic,  93 

cryptogenetic,  91 

nascentium,  91 

pathology,  91 

symptoms,  92 

treatment,  94 
Textor's  amputation,  211 
Theeitis,  279 

Thiersch's  skin-grafting,  224 
Thigh,  amputation  of,  213 
Thoracoplasty,  746 
Thoracotomy,  742 
Thorax,  gunshot  wounds,  189 

operations,  736 

stab-wounds,  733 

wounds,  733 
Thrombosis,  237 

arterial,  241 

cavernous  sinus,  577 

lateral  sinus,  577 

longitudinal  sinus,  577 

mesenteric,  890 

sinus,  577 

venous,  238 
Thrombus,  160 
Thj-mus  gland,  surgery,  693 
Thyro-glossal  cvsts,  681 

fistula,  68 f 
Th\Toid,  carcinoma,  692 

enlargement,  684 

inflammation,  684 

sarcoma,  692 

surgery,  684 

tumors,  692 
Thvroidectomv,  692 
Thyroiditis,  684 
Thyrotomy,  672 
Thyrotoxicosis,  688 
Tibia,  fracture  of,  376 
Tibio-tarsal  joint  dislocation,  413 
Tic  convulsif,  292 

douloureux,  289 
Toe,  supernumerary,  504 
Tongue,  abscess,  647 

carcinoma,  649 

chancre,  649 

excision,  651 

gumma,  649 

ichthyosis,  647 

sarcoma,  649 

surgery,  644 

syphihs,  649 

tuberculosis,  648 
Tongue-tie,  644 
Tonsil,  surgery,  663 


Tooth  wounds,  170 
Torsion,  229 
Torticollis,  537 

spasmodic,  292,  538 
Tourniquet,  194 
Toxemia,  70 

cryptogenetic,  71 
Toxic  ne))hritis,  974 

peritonitis,  805 
Toxins,  bacterial,  19 
Trachelorrhaphy,  1081 
Tracheloplasty,'l081 
Tracheotomy,  670 
Transcondylar  amputation,  213 
Transfusion,  direct,  145 
Transplantation,  bone,  504 

tendon,  525 
Transverse  myelitis,  608 
Traube-Hering  waves,  572 
Traumatic  asphj'xia,  727 

delirium,  71,  173 

fever,  71 
Trendelenburg's  operation,  243 
Trephine,  CJalt's,  563 

Hudson's,  563 
Trephining,  skull,  563 
Treponema  pallidum,  82 
Trichiniasis,  276 
Trigger  finger,  543 
Trochanter,  fracture,  368 
Truss,  758 

for  inguinal  hernia,  786 
Tubal  abortion,  1090 
Tubular  aneurysm,  249 
Tubo-ovarian  abscess,  1077 

cyst,  1098 
Tubercle,  77 
Tuberculin,  78 

test,  81 

focal  reaction,  81 
Tuberculoma,  brain,  581 
Tuberculosis,  76 

ankle,  500 

appendix,  864 

bladder,  965 

bone,  437 

breast,  704 

carpus,  502 

cutis,  263 

diagnosis,  80 

elbow,  501 

hip,  488 _ 

joints,  476 

kidnev,  982 

knee,  498_ 

lungs,  747 

lymph  nodes,  269,  676 

parotid,  625 

pathology,  77 

peritoneum,  815 

V.  Pirquet's  test,  81 

pleura,  746 

ribs,  731 

sacro-iliac  joint,-  502 

skin,  263 

spine,  602 


i.\i)i':.\ 


li:!'.) 


Tlllicrcillosis,  si)iii(',  ahsccss,  (lIMi 

sfcTiiiim,  TiVi 

tarsus,  ■)()(> 

tendon  slicallis,  27!) 

tfsticK",  10.')  t 

tonfiiu',  Ml 

tiratmcnt,  82 

wrist,  r)()2 
Tulxnculous  cavity,  SO 

dactylitis,  t.'ii) 

{iraniilation  tissue.  7!) 

fiununa,  7!) 

lynipiiadonilis  of  neck,  (J7() 

meningitis,  'u\) 

peritonitis,  SI") 

l)yeinia,  SO 

rheumatism,  474 

sinus,  SO 

ulcer,  SO 
Tufnell's  treatment  for  aneurysm,  253 
Tumors,  101 

abdominal,  diagnosis  of,  \)')'A 

adenoma,  1 1!) 

of  alveolar  bonier,  660 

of  appendix,  864 

of  bile-ducts,  942 

of  bladder,  966 

blastoma,  104 

blastomatoid,  107 

of  bone,  443 

of  brain, 581 

of  breast,  705 

cachexia,  103 

capsule.  102 

carcinoma,  119 

cartilaginous,  110 

of  carotid  gland,  680 

characteristics,  101 

chloroma,  114 

cholesteatoma,  129 

chondroma,  100 

chordoma,  114 

classification,  104 

consistency,  102 

cylindroma,  128 

cj'st  formation,  103 
sequestration,  130 

cyst  adenoma,  119 

cystoma,  129 

definition,  101 

desmoid,  277 

embryoma,  106 

endosteoma,  111 

endothelioma,  127 

epithelioma,  121 

excision,  131 

fibroid,  114 

fibroma,  108 

fibro-myxoma,  109 

fibro-sarcoma,  109 

form,  101 

formation,    Cohnheim's    theor}', 
103 
parasitic  theory,  104 
Ribbert's  theory,  104 

of  gall-bladder,  942" 


Tuniiirs,  glidtn.i,    I  I  1 

growth,   102 

hylic,  106 

malignant,  I  I  I 

hyi)ernci)hrom.'i,  127 

oi'  intestine,  894 

intraspinal,  617 

of  jaw,  660 

of  joints,  5();i 

keloid,  109 

of  kidney,  983 

of  larynx,  668 

IcpidiV,  106 

benign,  1  IS 
malignant,  1 19 
transitional,   127 

lipoma,  107 

of  liver,  941 

of  lung,  749 

lymphoma,  I  I  1 

lymphomatosis,  1 14 

malignancy,  103 

mediastinal,  732 

melanoma,  129 

mesothelioma,  127 

metastasis,  103 

mixed,  1C6 

of  muscle,  277 

myeloma,  113 

myelomatosis,  113 

myoma,  114 

mj'xoma,  109 

myxo-sarcoma,  109 

of  naso-pharynx,  665    . 

of  nerve,  293 

neuroma,  114 

odontoma,  112 

osteoma.  111 

ostoses,  112 

of  ovary,  1101 

of  pancreas,  950 

l)apinoma,  118 

of  i)arotid,  624 

l)erithelioma,  128 

of  pleura,  749 

psammoma,  128 

of  rectum,  913 

recurrence,  103 

rhabdomyoma,  114 

sarcoma,  114 

of  scalp,  552 

of  scrotum,  1063 

of  sigmoid,  913 

of  spleen,  953 

of  stomach,  873 

terato-blastoma,  105 

teratoma,  104 

of  testicle,  1057 

theories  of  formation,  103 

of  thyroid,  692 

xanthoma,  108 
Tyloma,  259 
Typhoid  arthritis,  472 

carriers,  927 

hemorrhage,  893 

perforation,  892 


1140 


INDEX 


Typhoid  periosteitis,  42o 
spine,  615 
spondylitis,  615 


Ulcer,  53 

callous,  55 
(luoflenal,  864 
chronic,  865 
hemoiThage.  868 
pei-foration.  867 
treatment,  866 
edematous,  54 
gastric,  864 
acute,  865 
callous,  865 
chronic,  865 
hemorrhage,  868 
open,  865 
operation,  867 
perforation,  867 
treatment,  866 
healthy.  54 
indolent,  55 
inflamed,  54 
irritable,  54 
Jacob's,  123 
leg,  55 

strapping,  56 
sj'philitic,  57 
MarjoUn's,  123 
neuralgic,  54 
perforating,  60.  261 
phagedenic,  54 
repair.  53 
rodent,  123 
simple,  54 
sloughing,  54 
tuberculous,  80 
varicose,  58 
warty,  58 
weak,  54 
Ulceration,  26,  53 

serpiginous,  53 
Ulcus  molle,  1005 
Ulna,  fracture,  348 
Umbihcal  fistula,  891 
hernia,  774 

.strangulated,  778 
Union  in  fractures,  303 

in  incised  wounds,  161 
Urachal  cvsts,  963 

fistul?e,  963 
Uranoplasty,  638 
Ureter,  catlieterization,  961 
Ureteral  calculus,  981 
Uretero-cervical  fistula,  1089 
Ureterolithotomy,  981 
Urethra,  foreign  bodies,  1016 
prolapse,  1018 
rupture.  1017 
stricture,  1018 

congenital.  1019 
dilatation,  1021 


Urethra,  stricture,  incision,  1022 

inflammatory,  1018 

inorganic,  IfJlS 

organic,  1019 

perineal  section,  1024 

spasmodic,  1019   . 

s\Tnptoms,  1019 

traumatic,  1019 

treatment,  1021 
surgery,  1015 
Urethral  fever,  1026 
Urethritis,  female,  1071 
gonococcic,  1010 
non-gonococcic,  1014 
Urethrotomy,  1022 
Urinarv  extravasation.  1017 
fever.  1026 
fistula,  1027 
Urine,  overflow  with  retention,  1016 
residual,  1016 
retention,  1015 
Uterus,  adenomyoma,  1105 
anteflexion,  1086 
anteversion,  1086 
carcinoma,  1109 
chorio-epithelioma,  1111 
deciduoma  malignum,  1111 
didelphys,  1070 
displacements,  1086 
do\\iiward  displacement,  1087 
fibroid,  1102 
fibrom\'oma,  1102 
hysteropexy,  1086 
malformation,  1070 
myoma,  1102 
perforation,  1093 
polyp,  1103 
procidentia,  1088 
prolapse,  1088 
retroflexion,  1086 
retroversion,  1086 
subinvolution,  1086 
vcntrosuspension,  1087 


Vaccixatiox,  143 
Vaccines,  45 

in  inflammation,  44 
Vagina,  absence,  1069 
Vaginal  hysterectomy.  1108 

operations,  preparation,  1068 
Vaginitis.  1071 

chronic,  1072 
\'alsalva's  treatment  for  aneurysm,  256 
Varicocele,  1061 

operation,  1062 
Varicose  aneurysm,  235 

veins,  242 

ulcer,  58 
Varix,  242 
Vein,  anesthesia,  158 

entrance  of  air,  234 
\'enereal  di-seases,  989 

warts,  259,  1049 


INDEX 


1141 


\'ciinus  ;Ul('Ul>sm,   I'.VA 

iicvi,  21") 
\'t'iitriil  licriiia,  772 
Vontriclos,  tappiiifi;  hit  oral,  5r)0 
Vontro-fixation  oi"  uterus,  1087 
VontrosusixMisioM  uterus,  1()S7 
Verruca,  2")!! 

Verruca'  acuminata",  lOlU 
Vertebra,  dislocation,  .')!)4 
Vertebra-,  fracture,  .'iit  I 

osteomyelitis,  (i()2 
\'erteljral  colunui,  dystropliies,  (il") 
\'esical  calculus,  !)()(> 
Vesication,  142 

Ve.sico-ut(>rine  fistula,  913,  1089 
Vesico-va^R-inal  fistula,  913,  1089 
Vicious  circle,  880 
Villous  arthritis,  4(12 
Visceroptosis,  898 
Volkmann's  contracture,  540 
Volvulus,  treatment,  889 
A'ulva,  carcinoma,  1112 

imjierf  orate,  10G9 
Vulvitis,  1071 
Wilvo-vafiinal  abscess,  1071 


W 


Wakdiiop's  ligation,  2.j.5 
Wart,  259 

venereal,  1049 
Wart}'  ulcer,  58 
Wassermann  reaction,  1001 
Wax,  Horsley's,  588 

Mosetig-Moorhof's,  435 
''Weaver's  bottom,"  267 
Webbed  fingers,  506 
\\m,  265 
Whitehead's  excision  of  tongue,  653 

hemorrhoid  operation,  908 

varnish,  638 
Whitlow,  279 
Wille's  test,  948 
Wiring  aneurysm,  256 
Witzel's  gastrostomy,  877 
Wolfe-Krause  skin-grafting,  225 
Wool-sorter's  disease,  87 
Wounds,  arrow,  170 

arterio-venous,  235 

bayonet,  170 

bites,  170 

blank  cartridge,  186 

bloodvessels,  233 

bullet,  183 

of  burste,  266 

contused,  167 

drainage,  165 

dressing,  166 

gunshot,  180 

of  abdomen,  191,  844 
of  bloodvessels,  186 
of  bones,  186 
character,  182 
of  diaphragm,  750 


WOiiiids,  gunshot,  of  liead,   188 
of  intestine,  845 
(tf  joints,  186 
<(f  liver,  .S47 
of  lung,  ISO 
of  nerves,  186 
of  pancreas,  847 
of  si)ine,  189 
of  sj)leen,  847 
of  stomach,  84() 
of  tendons,  18() 
of  thorax,  189 

of  heart,  236 

incised,  160 

dressing,  166 
healing,  161 

intestinal  suture,  830 

of  joints,  386 

lacerated,  167 

of  nuiscles,  273 

of  neck,  673 

of  nerves,  284 

open,  16() 

])oisoned,  170 

l)unctured,  169 

of  scalp,  552 

of  skull,  557 

small  shot,  185 

snake  l)ites,  170 

stab,  170 

of  abdomen,  844 
of  diajihragm,  749 
of  thorax,  733 

subcutaneous,  160 

suture,  165 

of  tendons,  277 

tooth,  170 
Wrist,  dislocation,  403 

excision,  470 

subluxation,  542 

tuberculosis,  502 
Wrist-joint  amputations,  206 
Wry-neck,  537 
Wveth's  method,  214 


Xanthoma,  108 
Xiphodynia,  322 
X-ray  dermatitis,  222 
in  fractures,  3C2 
therapeutic  uses,  223 


YoiiN(i's  operation,  1041 


ZUCKER(;USSMA(JEN,   872 

Zygoma,  fracture,  320 


